See also

Key points

1. Do not accept otitis media as the sole diagnosis in a sick febrile young child without exclusion of more serious causes (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 AOM are often multifactorial. Exposure to cigarette smoke from household contacts is a known modifiable risk factor

Assessment

History

• Recent onset ear pain (irritability in pre-verbal children)
• Fever
• Loss of appetite
• Vomiting
• Lethargy 
• Cochlear implant
• Immunocompromise

Examination

• Systemically unwell
• Ear examination:
• signs of acute inflammation of the tympanic membrane (TM): bulging, red, opaque TM
• a red TM alone is not AOM. The most common cause is a viral upper respiratory tract infection (URTI)

Otoscopic images of tympanic membranes (TM):

	Normal tympanic membrane TM is translucent The handle of the malleus is vertical No erythema
	Injected tympanic membrane Pink/red TM Often seen with fever, eustachian tube obstruction or viral URTI TM is transparent (there is no middle ear effusion) The handle of the malleus is well seen and is more horizontal
	Bulging and red tympanic membrane in AOM Loss of the TM landmarks, especially the handle of the malleus TM is opaque, may be red from inflammation or white from pus in the middle ear
	Otitis media with effusion (OME) “glue ear” TM is retracted with prominence of the handle of the malleus, which is also drawn in/more horizontal TM may be bulging or have an air-fluid level behind the TM Yellow/amber appearance is consistent with fluid Light reflex on otoscopic examination
	Perforated tympanic membrane with otorrhoea
	Otitis externa Ear is tender to examine Skin of the external ear canal is swollen and there can be thin pus

Management

In Infants, especially <6 months old, the diagnosis of AOM and OME can be inaccurate. Other diagnoses should be fully considered (see Febrile child)

Management may also differ for children from higher risk groups, such as those living in Aboriginal or Torres Strait Islander communities (see additional resources below)

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

• Most cases of AOM in children resolve spontaneously and antibiotics are not recommended
• Treat pain with adequate and regular simple analgesia. See Acute pain management
• As an adjunct, short-term use of topical analgesia eg 2% lignocaine (for injection), 1-2 drops or Benzocaine + Phenazone (Auralgan^®) applied to an intact tympanic membrane, may be effective for severe acute ear pain
• Decongestants, antihistamines and corticosteroids are not effective in AOM
• Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines
  

 


Complications

Tympanic membrane perforation

• AOM with TM perforation is common and results in otorrhoea and frequently, relief of pain
• Otorrhoea due to TM perforation should be distinguished from Otitis Externa

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 often with external auditory canal oedema and signs of AOM (see image below)
• Requires prompt treatment with appropriate intravenous antibiotics (eg 3rd generation cephalosporin)
• Consult ENT as may require surgical treatment


Acute mastoiditis

Other complications

• Other suppurative complications including intracranial spread of infection are rare
• Facial nerve palsy secondary to AOM should be discussed with ENT
• Long-term non suppurative complications include atelectasis of the TM and cholesteatoma

Otitis media with effusion (OME)

• OME, previously termed serous otitis or glue ear, is fluid in the middle ear without signs and symptoms of infection, other than transient hearing impairment
• The presence of a middle ear effusion is not a diagnostic sign of AOM (an effusion may not resolve for up to 12 weeks following AOM)
• 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

Consider consultation with local paediatric team when

• Children who are systemically unwell
• Neonates
• Children with signs of acute mastoiditis or who have 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, see Retrieval Services

Consider discharge when

No signs of complications

Additional resources

Otitis media guidelines for Aboriginal and Torres Strait Islander children

Parent information

Ear Infections and Glue Ear 

 

Last Updated June 2021