Overview
Acute Otitis Media (Child)
1. Clinical Overview
Summary
Acute Otitis Media (AOM) is an acute infection of the middle ear, one of the most common childhood infections. It affects approximately 80% of children by age 3, with peak incidence between 6-18 months. AOM typically follows a viral upper respiratory tract infection (URTI) that causes Eustachian tube dysfunction, Leading to middle ear effusion and secondary bacterial infection. The most common bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae (Non-typeable), and Moraxella catarrhalis. Children present with Ear Pain (Otalgia), Fever, Irritability, and examination reveals a Bulging, Erythematous, Opacified Tympanic Membrane with reduced mobility. Most cases are self-limiting and resolve without antibiotics. Management follows a Watchful Waiting strategy for uncomplicated cases in children ≥2 years, with Amoxicillin as first-line antibiotic when indicated. Complications (Mastoiditis, Meningitis, Facial nerve palsy) are rare but serious. [1,2,3]
Clinical Pearls
"Bulging TM is Key": A bulging, erythematous, immobile tympanic membrane is the hallmark finding.
"Crying ≠ Red TM": Crying can cause erythema of the TM. Look for bulging and opacity.
"Most Resolve Without Antibiotics": ~80% resolve spontaneously. Watchful waiting is appropriate in many cases.
"Safety-Net": Advise parents to return if symptoms worsen, Child becomes systemically unwell, Or new symptoms develop.
2. Epidemiology
Demographics
| Factor | Notes |
|---|---|
| Prevalence | ~80% of children have ≥1 episode by age 3. |
| Peak Incidence | 6-18 months. |
| Sex | Male > Female (Slightly). |
| Season | Winter (Correlates with respiratory virus season). |
Risk Factors
| Risk Factor | Notes |
|---|---|
| Age 6-18 months | Shorter, More horizontal Eustachian tube. |
| Daycare Attendance | Increased exposure to respiratory pathogens. |
| Bottle Feeding (While Supine) | Vs Breastfeeding. |
| Passive Smoke Exposure | |
| Craniofacial Abnormalities | Cleft palate, Down syndrome. Eustachian tube dysfunction. |
| Sibling with Recurrent AOM | |
| Pacifier Use | |
| Not Breastfed | Protective effect of breastfeeding. |
Microbiology
| Pathogen | Proportion |
|---|---|
| Streptococcus pneumoniae | ~25-50% (Decreasing with PCV vaccination). |
| Haemophilus influenzae (Non-typeable, NTHi) | ~15-30%. |
| Moraxella catarrhalis | ~10-20%. |
| Viral | Often initiates disease. RSV, Rhinovirus, Influenza, Adenovirus. |
3. Pathophysiology
Mechanism
- Viral URTI: Causes nasopharyngeal inflammation.
- Eustachian Tube Dysfunction: Swelling obstructs Eustachian tube.
- Negative Middle Ear Pressure: Air reabsorbed from middle ear.
- Effusion (OME): Fluid accumulates in middle ear.
- Bacterial Colonisation: Bacteria from nasopharynx ascend through Eustachian tube.
- Acute Suppurative Infection: Pus in middle ear. Bulging TM.
- Resolution or Complications: Most resolve. Some perforate (Otorrhoea). Rare mastoiditis.
Eustachian Tube in Children
- Shorter, Wider, More horizontal than adults.
- Predisposes to reflux of nasopharyngeal contents into middle ear.
4. Clinical Presentation
Symptoms
| Symptom | Notes |
|---|---|
| Ear Pain (Otalgia) | Often severe. May wake from sleep. Infants: Ear tugging, Irritability. |
| Fever | Common. May be high-grade. |
| Irritability | Especially in infants. |
| Poor Feeding | |
| Sleep Disturbance | |
| Hearing Impairment | Conductive loss (Effusion). |
| Preceding URTI Symptoms | Runny nose, Cough. |
| Otorrhoea | If TM perforates. Purulent discharge. Often relieves pain. |
Examination Findings (Otoscopy)
| Finding | Notes |
|---|---|
| TM Appearance | Bulging (Most specific). Erythematous. Opaque/Cloudy. Loss of light reflex. |
| TM Mobility | Reduced (Pneumatic otoscopy). |
| Perforation | May be seen. Often pinhole. Pus in canal. |
| Otorrhoea | Purulent discharge if perforated. |
Differential Diagnosis
| Condition | Key Features |
|---|---|
| Otitis Media with Effusion (OME / Glue Ear) | Effusion without acute inflammation or infection. TM retracted, Not bulging. Amber/Dull. Conductive hearing loss. |
| Otitis Externa | Pain on tragal pressure, Auricular movement. Canal erythema/Swelling. TM usually normal. |
| Foreign Body | Visible on otoscopy. |
| Referred Pain | From teething, Pharyngitis. TM normal. |
5. Diagnosis
Clinical Diagnosis
- Based on History (Acute onset, Ear pain, Fever, Preceding URTI) + Otoscopy (Bulging, Erythematous, Immobile TM).
Diagnostic Criteria (AAP)
| Criteria |
|---|
| 1. Moderate-Severe bulging of TM OR New onset otorrhoea not due to otitis externa. |
| 2. Mild bulging of TM AND Recent (less than 48h) onset of ear pain or intense erythema. |
| 3. Presence of middle ear effusion (Bulging, Limited mobility, Air-fluid level, Otorrhoea). |
Investigation
| Investigation | Notes |
|---|---|
| Tympanometry | Flat trace (Type B) = Effusion. Not routinely done for AOM. |
| Swab (If Otorrhoea) | Culture for treatment failure or recurrent AOM. |
6. Management
Management Algorithm
ACUTE OTITIS MEDIA SUSPECTED
(Ear pain, Fever, Bulging TM)
↓
CONFIRM DIAGNOSIS (Otoscopy)
- Bulging TM + Erythema + Reduced mobility
↓
ASSESS SEVERITY
┌───────────────┬───────────────┬───────────────┐
MILD AOM MODERATE-SEVERE HIGH-RISK /
(Unilateral, AOM RED FLAGS
less than 48h, Mild (Bilateral OR (See below)
symptoms, Severe symptoms
Age ≥2) OR less than 2 years with
bilateral)
↓ ↓ ↓
**WATCHFUL **ANTIBIOTICS** **URGENT
WAITING** (Immediate) REFERRAL**
↓
WATCHFUL WAITING (For Suitable Cases)
┌──────────────────────────────────────────────────────────┐
│ - Symptom relief: Paracetamol / Ibuprofen │
│ - No immediate antibiotics │
│ - **Safety-Net Advice**: │
│ - Return if: Symptoms worsen, Not improving by 48h, │
│ Child becomes very unwell, New symptoms (Rash, │
│ Stiff neck) │
│ - **Delayed Prescription** option: │
│ - Provide prescription to use if not improving by │
│ 48-72h │
└──────────────────────────────────────────────────────────┘
↓
ANTIBIOTIC THERAPY
┌──────────────────────────────────────────────────────────┐
│ **FIRST-LINE: AMOXICILLIN** │
│ - Dose: 40-50 mg/kg/day in 3 divided doses (BNFc) │
│ OR 80-90 mg/kg/day in high-resistance areas │
│ - Duration: **5 days** (NICE) │
│ │
│ **PENICILLIN ALLERGY:** │
│ - Clarithromycin or Erythromycin │
│ - Duration: 5 days │
│ │
│ **SECOND-LINE (If Amoxicillin Fails):** │
│ - Co-Amoxiclav (Amoxicillin-Clavulanate) │
│ - Covers Beta-lactamase producers (H. influenzae, │
│ M. catarrhalis) │
└──────────────────────────────────────────────────────────┘
↓
RED FLAGS / INDICATIONS FOR URGENT REFERRAL
┌──────────────────────────────────────────────────────────┐
│ - **Mastoiditis**: Tender, Red, Swollen mastoid. │
│ Protruding ear. SURGICAL EMERGENCY. │
│ - **Facial Nerve Palsy** │
│ - **Meningism**: Stiff neck, Photophobia, Bulging │
│ fontanelle │
│ - **Systemically Unwell / Sepsis** │
│ - **Labyrinthitis**: Vertigo, Nystagmus, Hearing loss │
│ - **Cholesteatoma Suspected** │
│ - **Immunocompromised Child** │
│ - **Age less than 3 months with Fever >38°C** │
└──────────────────────────────────────────────────────────┘
Indications for Immediate Antibiotics
| Indication |
|---|
| Age less than 2 years with Bilateral AOM. |
| Otorrhoea (Perforated TM with discharge). |
| Systemically Unwell. |
| Severe Symptoms (High fever >39°C, Severe pain >48h). |
| Immunocompromised. |
7. Complications
| Complication | Notes |
|---|---|
| Tympanic Membrane Perforation | Common. Often heals spontaneously. Otorrhoea. |
| Otitis Media with Effusion (OME / Glue Ear) | Persistent effusion after AOM. May cause hearing impairment. |
| Hearing Loss | Conductive (Effusion). Sensorineural (Rare – Labyrinthitis). |
| Recurrent AOM | ≥3 episodes in 6 months OR ≥4 in 12 months. Consider grommets. |
| Chronic Suppurative Otitis Media (CSOM) | Persistent perforation with ongoing discharge. |
| Acute Mastoiditis | Infection spreads to mastoid air cells. Red, Tender, Swollen mastoid. Ear pushed forward. Surgical emergency. |
| Facial Nerve Palsy | Rare. Infection near facial nerve canal. |
| Labyrinthitis | Inner ear infection. Vertigo. Sensorineural hearing loss. |
| Meningitis | Rare. Intracranial extension. |
| Brain Abscess | Very rare. Intracranial extension. |
| Cholesteatoma | Chronic complication. Squamous epithelium in middle ear. Bone erosion. |
8. Prognosis and Outcomes
| Factor | Notes |
|---|---|
| Self-Resolution | ~80% resolve within 2-3 days without antibiotics. |
| With Antibiotics | Marginally faster resolution. NNT ~7-8 to prevent 1 child having pain at 2-7 days. |
| Recurrence | Common. ~30% have recurrent AOM. |
| Hearing | Usually returns to normal after effusion resolves (May take weeks-months). |
| Complications | Rare with appropriate management. |
9. Prevention
| Measure | Notes |
|---|---|
| Pneumococcal Conjugate Vaccine (PCV) | Reduces AOM from vaccine serotypes. Routine childhood immunisation. |
| Influenza Vaccine | Reduces AOM associated with influenza. |
| Breastfeeding | Protective. |
| Avoid Smoke Exposure | |
| Avoid Supine Bottle Feeding |
10. Evidence and Guidelines
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| AOM | NICE (NG91 Otitis Media) | Watchful waiting for mild AOM in children ≥2. Immediate antibiotics if less than 2 with bilateral, Otorrhoea, Systemically unwell. Amoxicillin first-line. 5-day course. |
| AOM | AAP | Similar. Emphasis on accurate diagnosis with pneumatic otoscopy. |
11. Patient and Layperson Explanation
What is Acute Otitis Media?
An ear infection is when germs cause an infection in the middle part of your child's ear, Behind the eardrum. It often happens after a cold.
What are the symptoms?
- Ear pain (Your child may tug at their ear).
- Fever.
- Being irritable or crying more than usual.
- Not eating well.
- Sometimes discharge from the ear.
Does my child need antibiotics?
Not always. Most ear infections get better on their own within a few days with just pain relief. Your doctor may suggest watching and waiting, And give you a prescription to use only if your child isn't getting better.
Antibiotics are usually given if:
- Your child is under 2 with infection in both ears.
- There is discharge from the ear.
- Your child is very unwell.
What should I do?
- Give regular Paracetamol or Ibuprofen for pain and fever.
- Keep your child comfortable.
- See a doctor if symptoms get worse, Your child becomes very unwell, Or new symptoms (Rash, Stiff neck) appear.
When should I seek help urgently?
- Swelling or redness behind the ear.
- Drooping of one side of the face.
- Child is drowsy, Very unwell, Or has a stiff neck.
12. References
Primary Sources
- National Institute for Health and Care Excellence. Otitis media (acute): antimicrobial prescribing (NG91). 2018.
- Lieberthal AS, et al. The Diagnosis and Management of Acute Otitis Media (AAP Clinical Practice Guideline). Pediatrics. 2013;131(3):e964-e999. PMID: 23439909.
- Rovers MM, et al. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet. 2006;368(9545):1429-1435. PMID: 17055944.
13. Examination Focus
Common Exam Questions
- Key Otoscopic Finding: "What is the most specific otoscopic finding for AOM?"
- Answer: Bulging Tympanic Membrane.
- Watchful Waiting: "In which children is watchful waiting appropriate?"
- Answer: Age ≥2 years, Mild symptoms, Unilateral AOM, No otorrhoea, Not systemically unwell.
- First-Line Antibiotic: "What is the first-line antibiotic for AOM?"
- Answer: Amoxicillin.
- Complication Sign: "What sign suggests acute mastoiditis?"
- Answer: Swollen, Red, Tender mastoid (Behind the ear), Ear pushed forward/Outward.
Viva Points
- Common Pathogens: S. pneumoniae, NTHi, M. catarrhalis.
- Crying Causes Red TM: Don't diagnose AOM on erythema alone. Look for bulging.
- Grommets for Recurrent AOM: Consider if ≥3 episodes in 6 months or ≥4 in 12 months.
- PCV Reduces AOM: But doesn't eliminate (Non-vaccine serotypes, Other organisms).
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.