Acute Otitis Media
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Direct answer
Acute otitis media is an infection of the middle ear that is diagnosed when a middle-ear effusion appears with signs of acute inflammation, usually after an upper respiratory viral infection. Streptococcus pneumoniae, nontypeable Haemophilus influenzae and Moraxella catarrhalis cause most bacterial cases. Management depends on age and severity, and watchful waiting is an accepted option only for older children with non-severe disease.
What you must remember
- Diagnosis: recent onset, a middle-ear effusion and inflammation; bulging of the tympanic membrane is the most specific sign, while redness alone is unreliable in a crying child.
- Organisms: Streptococcus pneumoniae, nontypeable Haemophilus influenzae and Moraxella catarrhalis, with beta-lactamase production common in the latter two.
- Age and severity: infants under six months are always treated, while children two years and older with non-severe illness may be observed (6 to 23 months only if unilateral and non-severe).
- First-line antibiotic: high-dose amoxicillin in children without penicillin allergy, with amoxicillin-clavulanate used after treatment failure or recent antibiotic exposure.
- Pain relief: paracetamol or ibuprofen treats pain and fever, and is part of care whatever the antibiotic decision.
- Complications: mastoiditis, subperiosteal abscess, facial nerve palsy, labyrinthitis and, rarely, meningitis.
- Prevention: pneumococcal conjugate vaccination reduces the burden of pneumococcal otitis, and breastfeeding and avoidance of smoke exposure are also protective.
A stepwise approach to a toddler who wakes at night with ear pain
A 2-year-old has fever, pulls at the right ear and has a runny nose for a day. The approach runs in a fixed sequence.
- Confirm the onset. Acute onset over a day or two with ear pain or fever supports the diagnosis, whereas chronic discharge points to another cause.
- Examine the drum on pneumatic otoscopy. Look for bulging, loss of landmarks and reduced mobility, and remember that crying and fever also redden the drum.
- Assess severity and laterality. Note the temperature, toxicity, age and whether one or both ears are involved, since these drive the decision.
- Choose treat or observe. Treat infants under six months and any severe disease; in older children with non-severe illness, arrange review at 48 to 72 hours with clear safety-net advice.
- Prescribe and review. Give high-dose amoxicillin for a standard course with analgesia, and escalate to amoxicillin-clavulanate or refer for myringotomy if there is no response.
Where the exam tries to catch you
Three errors recur on this topic.
- Trap: treating every red drum with antibiotics Correct: diagnosis needs bulging or effusion plus acute symptoms, because crying and viral infection both cause redness.
- Trap: using antibiotics for every child regardless of age Correct: watchful waiting is valid for children two years and older with non-severe disease, while infants under six months are always treated.
- Trap: choosing a macrolide as first-line treatment Correct: high-dose amoxicillin is first-line, and macrolides are reserved for children with a true penicillin allergy.
Frequently asked questions
What are the most common organisms in acute otitis media?
Streptococcus pneumoniae, nontypeable Haemophilus influenzae and Moraxella catarrhalis cause most bacterial cases of acute otitis media in children. Beta-lactamase production is common in Haemophilus and Moraxella, which is why amoxicillin-clavulanate is used after first-line treatment fails.
When is watchful waiting appropriate in acute otitis media?
Watchful waiting in acute otitis media is appropriate for children aged two years and older with non-severe illness and an uncertain diagnosis. These children are reviewed at 48 to 72 hours, and antibiotics start if symptoms persist or worsen, whereas infants under six months are not observed.
Which antibiotic is first-line for acute otitis media in children?
High-dose amoxicillin is the first-line antibiotic for acute otitis media in children without penicillin allergy. Macrolides or other alternatives are reserved for children with a true penicillin allergy, and amoxicillin-clavulanate is used when first-line treatment has failed.
Which complications of acute otitis media need urgent referral?
Mastoiditis, subperiosteal abscess, facial nerve palsy and labyrinthitis are complications of acute otitis media that need urgent referral. Suspected intracranial spread, such as meningitis, needs emergency admission and specialist review.