Otitis Media
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Direct answer
Acute otitis media is a usually viral-triggered middle-ear infection of young children: otalgia and fever with a bulging, hyperaemic tympanic membrane that may perforate and discharge. High-dose oral amoxicillin for 7 to 10 days is standard first-line treatment when antibiotics are indicated, with watchful waiting an option in milder older children. Its stubborn aftermath, otitis media with effusion (glue ear), is the commonest cause of hearing loss in children and is treated with myringotomy and grommet insertion when bilateral and persistent beyond three months.
What you must remember
- Diagnostic triad: earache plus fever plus a bulging, immobile, congested tympanic membrane on pneumatic otoscopy; auto-perforation relieves pain and releases mucopurulent discharge.
- Common organisms: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis; first-line drug is amoxicillin (Indian standard texts 40–50 mg per kg per day, newer Western guidance up to 80–90 mg per kg per day in two divides).
- Watchful waiting for 48–72 hours with analgesia is acceptable in children above two years with mild, unilateral disease — a favourite option in management questions.
- Otitis media with effusion presents as painless hearing loss with a dull, retracted drum, fluid level or air bubbles; the tympanogram is flat (type B).
- Grommet (ventilation tube) criteria: effusion persisting over three months, significant hearing loss, or recurrent acute episodes; adenoidectomy is added when adenoid hypertrophy contributes.
- Risk factors to quote: bottle feeding, passive smoking, day-care attendance, cleft palate and allergic rhinitis; exclusive breastfeeding for the first six months is protective.
- Frequent acute attacks — roughly seven in a year or five yearly for two consecutive years — justify tonsil and adenoid assessment and consideration of tubes.
A typical exam case
A two-year-old, brought for crying and tugging at the right ear for a day, has fever of 38.6 degrees Celsius and a cold for the past week. Otoscopy shows a pink, bulging drum with obliterated landmarks; pneumatic otoscopy confirms it does not move. This is acute otitis media on top of a viral upper respiratory infection that reached the middle ear through the Eustachian tube. Management runs in order: paracetamol for pain and fever, then high-dose amoxicillin for 7 to 10 days since the child is under two and bilaterally unwell, and reassurance that a small anterior perforation, if one develops, usually heals by itself.
Fast-forward six weeks in the same story. The pain never returned, but the mother says the child turns up the television and sits close to it at playschool. The drum is now dull and retracted with an amber fluid level. This is otitis media with effusion — sterile fluid trapped after the acute infection, not persistent infection, so antibiotics are not the answer. Confirm with a flat type B tympanogram and document the hearing level. Because both ears are involved and it has crossed three months with documented hearing loss, the child goes for myringotomy with grommet insertion, which restores hearing immediately; the tube extrudes spontaneously in six to twelve months. Watching for speech and language milestones closes the loop.
How the exam frames it
The recurring contrast is painful versus painless. Bulging drum with fever answers acute otitis media; retracted drum with hearing loss and no fever answers effusion. Expect one question on the tympanogram (type B means effusion), one on antibiotic choice with dose band, and one on the grommet rule of "three months, both ears, documented loss". The planted trap is prescribing repeated antibiotic courses for glue ear — the fluid is sterile, and the examinable answer is ventilation, not another course of amoxicillin.
Frequently asked questions
Which organisms most commonly cause acute otitis media?
Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis, typically following a viral upper respiratory infection.
What is the first-line antibiotic and a commonly tested dose?
Amoxicillin, 40–50 mg per kg per day per standard Indian texts, with newer guidance favouring high-dose 80–90 mg per kg per day in two divided doses for resistant pneumococci.
How does otitis media with effusion differ from acute otitis media?
Effusion is sterile fluid behind an intact drum causing painless conductive hearing loss, whereas acute otitis media is an inflamed, bulging, painful drum with fever.
What are the indications for grommet insertion?
Bilateral effusion persisting beyond three months with documented hearing loss, recurrent acute otitis media, or effusion with speech, balance or developmental concern.
What does a type B tympanogram indicate?
A flat trace with no compliance peak, meaning middle-ear fluid (or a patent perforation) behind an intact drum.