Acute Otitis Media

Acute otitis media (AOM) is a common problem in early childhood; 2/3 of children
have at least one episode by age 3, and 90% have at least one episode by school entry.
Peak age prevalence is 6-18 months.
Causes:
o

viral (25%)

Streptococcus pneumoniae (35%)

non-typable strains of Haemophilus influenzae (25%)

Moraxella catarrhalis (15%).

Assessment
Note: A child with otitis media can also have serious bacterial infection such as septicaemia
or meningitis. If systemically unwell, consider coexistent causes of sepsis - do not accept
otitis media as the sole diagnosis in a sick febrile young child without elimination of a
more serious cause. (See febrile child guideline)
History:
fever, ear pain (irritability in pre-verbal children) +/- anorexia, vomiting, lethargy.

Examination
o

The usual middle ear landmarks (handle of malleus, incus, light reflex) are not
well seen.

The tympanic membrane (TM) is dull and opaque, and may be bulging. The
TM colour varies but is characteristically yellow-grey.

On pneumatic otoscopy TM mobility is reduced.

There may be associated signs of URTI, such as coryza, red tonsillopharynx,

cough etc. The features suggest the infection is viral.

Many febrile or crying children have red TMs (just as they have red cheeks). A
red TM alone is not acute otitis media.

It is not usually necessary to remove wax from the ear canals of febrile
children

Complications

Perforation of the TM results in purulent otorrhoea, and usually relief of pain.

Febrile convulsions are commonly related to AOM.

Suppurative complications such as mastoiditis, suppurative labyrinthitis or

intracranial infection (meningitis, extradural or subdural abscess, brain abscess) are
very uncommon in our population.

Other potential complications include facial nerve palsy, lateral sinus

thrombosis, and benign intracranial hypertension.

Serous otitis media ("glue ear")

Serous middle ear effusion commonly persists for several weeks or even months following
an episode of AOM. This may be recurrent, even in the absence of identifiable episodes of
AOM, and often causes conductive hearing loss. The long-term effects on language, literacy
and cognitive development are unclear. Parental smoking is an important avoidable risk
factor. The use of dummies should be limited to settling, as prolonged use has been shown
to be associated with otitis media.

Management
Most cases of AOM in children resolve spontaneously. Antibiotics provide a small reduction
in pain beyond 24 hours in only about 5% of children treated. The modest benefit must be
weighed against the potential harms related to antibiotic use, both for the individual patient
(adverse effects) and at a population level (resistance pressure). It has been shown that not
using antibiotics for otitis media is acceptable to parents if the reasons are explained clearly.
Pain is often the main symptom, so adequate analgesia is very important Analgesia
guideline. Paracetamol 20-30 mg/kg for 2-3 doses/day should be given if pain is significant.
Short-term use of topical 2% lignocaine drops applied to the tympanic membrane has been
shown to be effective for severe acute ear pain. Decongestants, antihistamines and
corticosteroids have not been shown to be effective in AOM.
The following flow-diagram provides a recommended management scheme:

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Otitis_Media/