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Otitis Media


Definition of otitis media

  • Otitis media is a very common middle ear infection seen in kids; the vast majority will have at least one episode. It is rare in over-5s.
  • The majority can be managed on an outpatient basis with/without oral antibiotics.


Causes of otitis media

  • Young age (smaller, less tortuous Eustachian tube with more patency)
  • Children with older siblings or who have repeated respiratory infections are at more risk
  • Parental smoking increases risk


Clinical features of otitis media

  • Earache in older patients; tugging/pulling at ear in children
  • Non-specific symptoms
    • Poor feeding, irritability, cough, rhinorrhoea
  • Often co-incident with LRTI
  • High fever (may give febrile convulsions)


Overview of otitis media from an ED physician


Examination in otitis media

  • Severe bulging eardrum or new onset ear discharge (purulent and not due to otitis externa) often associated with relief of symptoms (acute otitis media – AOM)
  • Mild bulging TM/very red TM requires correlation with symptoms from history
  • Hearing loss (but not usually detected in a young, crying child)
  • Examination can be tricky in very young children under 6 months


Hospital admission with otitis media

  • Admission required
    • Under  3 months and fever >38
    • Complicated AOM e.g. mastoiditis, facial palsy
  • Consider admission
    • Under  3 months
    • 3-6 months and fever >39
    • Systemically very unwell


Treatment of otitis media as an outpatient

  • Pain relief
    • Ibuprofen or paracetamol – alternate between the two if distress not helped by single agent.
  • Antibiotics
    • The evidence for this is mainly from studies in high-income countries. (Venekamp 2014)
    • 82% of children settle without antibiotics.
    • For every 20 children treated with antibiotics, one will experience reduction in pain between days 2-7.
    • For every 33 children treated, 1 tympanic membrane perforation will be prevented.
    • For every 11 children treated, 1 episode of contralateral AOM will be prevented.
    • However, for every 14 children treated, 1 child will experience adverse effects of vomiting, diarrhoea or rash.
  • A safe strategy would be to give immediate antibiotics to the following:
    • 4 days or more of symptoms
    • Systemically unwell
    • Significant comorbidities
  • Consider immediate antibiotics in:
    • Children under 2 with bilateral OM
    • Patients with perforation or discharge
  • Otherwise consider delayed prescription after 3-4 days or if symptoms worsen:
    • The first line is amoxicillin (5 days) or erythromycin/clarithromycin if pencillin allergic.
    • In ruptured eardrum, see at 3 weeks, again at six weeks if no resolution, and refer on if still unresolved
  • Also refer those with more than 4 episodes in six months


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