See also

Febrile child
Sepsis assessment and management  

Key Points

1. Do not accept otitis media as the sole diagnosis in a sick febrile young child without exclusion of a more serious cause. (See  Febrile child)
2. Diagnosis requires acute onset and an abnormal ear examination with signs of middle ear inflammation and middle ear effusion.
3. Avoid the routine use of antibiotic treatment for acute otitis media.

Background

Acute otitis media (AOM) is a common problem in early childhood

• 75% of children have at least one episode by school age
• Peak age prevalence is 6-18 months

Causes of acute otitis media are often multifactorial. Exposure to cigarette smoke from household contacts is a known modifiable risk factor.

Assessment

History:

Features: recent onset ear pain (irritability in pre-verbal children), fever, anorexia, vomiting, lethargy.

Examination:
Signs of acute inflammation of the tympanic membrane (TM)

• Including a haemorrhagic, injected or cloudy appearance
• Many febrile or crying children have red TMs. A red TM alone is not AOM.

Middle ear effusion

• Loss of TM landmarks, particularly the malleus, and light reflex on otoscopic examination.
• The TM may be bulging, have an air-fluid level behind the tympanic membrane or perforation of the tympanic membrane with otorrhoea. Otorrhoea due to TM perforation should be distinguished from otitis externa.
• Pneumatic otoscopy is the best method to diagnose middle ear fluid by demonstrating reduced TM mobility.
• The presence of a middle ear effusion, is not a diagnostic sign of AOM, as an effusion may not resolve for up to 12 weeks following AOM.

Do not attempt removal of wax from the ear canals to assess for acute otitis media as it is unlikely to alter management.

Management

Investigations

There is no role for routine diagnostic investigation for AOM.

• Diagnostic imaging such as CT and MRI is usually only required in children with suspected intracranial complications.

Treatment

Symptomatic treatment with adequate and regular analgesia is very important. See Analgesia guideline.

• As an adjunct, short-term use of topical 2% lignocaine, 1-2 drops applied to an INTACT tympanic membrane may be effective for severe acute ear pain. 
• Decongestants, antihistamines and corticosteroids are not effective in AOM.

Most cases of AOM in children resolve spontaneously. The routine use of antibiotic treatment should be avoided.

Infants <6 months old, including neonates: AOM is difficult to ascertain, and other diagnoses should be fully considered (see Febrile child).
Infants 3-6 months of age: clear diagnosis of AOM and systemically well - manage as per flowchart below. Otherwise see Febrile child.

Complications

Tympanic membrane perforation

AOM with TM perforation is common and results in otorrhoea and frequently, relief of pain. TM perforation does not alter AOM management (see flowchart).

Acute mastoiditis (AM)

Acute mastoiditis, although rare, is the most common suppurative complication of AOM and may be associated with intracranial complications.

• The diagnosis of AM is based on post auricular inflammatory signs (erythema, oedema, tenderness or fluctuance), a protruding auricle/external auditory canal oedema and signs of AOM.
• Requires prompt treatment with appropriate intravenous antibiotics (flucloxacillin plus 3rd generation cephalosporin).
• ENT involvement is required and some cases may require surgical treatment.

Acute mastoiditis: post auricular inflammatory signs (erythema/swelling/pain) and protruding auricle. 

Otitis Media with Effusion (OME)

Otitis media with effusion, previously termed serous otitis or glue ear, is fluid in the middle ear without signs and symptoms of infection and is often asymptomatic, other than transient hearing impairment

Antibiotics and ENT referral are not routinely required for OME, as the majority of cases occur after an episode of AOM and resolve spontaneously with no long term effects on language, literacy or cognitive development.

Persistent effusion beyond 3 months should trigger a hearing assessment and ENT involvement/referral.

Other complications

• Other suppurative complications include intracranial spread of infection - very rare in our population.
• Facial nerve palsy secondary to AOM - should be discussed with ENT.
• Non suppurative complications (long term) - atelectasis of the TM, cholesteatoma.

Consider consultation with local paediatric team when:

Children who are systemically unwell
Neonates
Children with acute mastoiditis or a cochlear implant should be discussed with ENT

Consider transfer when:

Children requiring care beyond the level of comfort of the local hospital.

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

Consider discharge when:

Adequate pain relief attainable

• Most children can be managed at home with symptomatic treatment with or without antibiotic treatment.

No signs of complications

Parent information sheet

• Ear Infections (HTML version)   
• Glue Ear (HTML version)

Last Updated April 2018