Acute Otitis Media (AOM)
Acute otitis media (AOM) is an acute inflammation of the middle ear with effusion and rapid onset symptoms of ear infection, most commonly ear pain.
This updated UKMLA guide to acute otitis media (AOM) is based on NICE NG91 and NICE CKS, which covers causes, symptoms, complications, diagnosis and management.
Causes
AOM can be caused by both bacteria and viruses. It is common for both bacterial and viral infections to be present at the same time.
| Bacterial pathogens |
|
| Viral pathogens |
|
Risk Factors
- Children (due to the shorter and more horizontal eustachian tubes)
- Children from birth to 4 y/o are most likely to present with AOM
- Male
- Smoking and/or passive smoking
- Increased exposure to viral illness (e.g. frequent contact with other children, having siblings)
- Craniofacial abnormalities (e.g. cleft palate)
- Gastro-oesophageal reflux
- Immunodeficiency
- Recurrent URTI
Clinical Features
AOM typically presents with an acute onset of otalgia (ear pain)
- Fever
- AOM can result in a perforated tympanic membrane, indicated by
- Sudden relief of pain
- Discharge from the ear (otorrhoea)
- Hearing loss
- Younger children tend to present slightly differently
- Ear tugging / rubbing / holding
- Non-specific symptoms like fever, crying, poor feeding, restlessness, behavioural changes, cough, rhinorrhoea
Otoscopic examination findings:
- Red / yellow / cloudy tympanic membrane
- Signs of middle ear effusion
- Bulging tympanic membrane
- Air-fluid level behind the tympanic membrane
- Loss of normal landmarks
- Signs of tympanic membrane perforation
- Visible tear / hole in the tympanic membrane
- Discharge in the external auditory canal
Clinical features that are less suggestive of AOM:
- Non-bulging tympanic membrane
- Presence of an air-fluid level, but a non-bulging tympanic membrane
These findings are more suggestive of middle ear effusion (glue ear) – characterised by fluid in the middle ear but absence of acute ear infection features.
Complications
More common complications:
- Tympanic membrane perforation (usually temporary) → conductive hearing loss
- Labyrinthitis (→ hearing loss + vertigo + N&V + nystagmus)
- Chronic suppurative otitis media
Rare but serious complications:
- Mastoiditis (see the Mastoiditis article for more information)
- Facial nerve (CN VII) palsy
- Intracranial complications
- Meningitis
- Intracranial abscess
- Sinus venous thrombosis
Red flag symptoms that indicate serious complications:
| Red flag symptoms | Suggestive complication |
|---|---|
|
Intracranial complications (meningitis, abscess, venous sinus thrombosis) |
|
Labyrinthitis |
|
Mastoiditis |
|
Facial nerve (CN VII) palsy |
Investigation and Diagnosis
AOM is a clinical diagnosis based on
- Clinical history, and
- Otoscopic examination findings
Management
Admission Criteria
Admit for immediate specialist assessment if ANY of the following:
- Severe systemic infection
- Presence of red flag symptoms suggesting a serious complication
- <3 m/o with temperature of ≥ 38°C
Red flag symptoms that indicate serious complications:
| Red flag symptoms | Suggestive complication |
|---|---|
|
Intracranial complications (meningitis, abscess, venous sinus thrombosis) |
|
Labyrinthitis |
|
Mastoiditis |
|
Facial nerve (CN VII) palsy |
General Advice / Conservative Management
| Patient education | AOM usually lasts for 3 days, but possibly up to 1 week
|
| Symptom management |
There is no evidence to support the use of decongestants and antihistamines |
Antibiotic Therapy
Indications for Antibiotics
Indications for immediate antibiotic prescription:
- Systemically unwell
- Features of more serious illness / conditions (e.g. mastoiditis)
- At risk of complications
Consider antibiotics if:
- Symptoms not improving within 3 days or worsening significantly or rapidly at any time
- Bilateral AOM in <2 y/o
- Presence of ear discharge (suggesting perforated tympanic membrane)
NICE notes that both viral and bacterial causes of AOM are usually self-limiting and do not routinely require antibiotics.
As such, there are no strict, clean-cut criteria for antibiotic use. Instead, NICE emphasises clinical judgement, highlighting that antibiotics provide limited symptomatic benefit, do not significantly reduce the risk of common complications (which are rare regardless), and carry potential adverse effects.
Choice of Antibiotics
1st line: amoxicillin for 5-7 days
2nd line:
- If penicillin allergic: clarithromycin for 5-7 days
- If pregnant + penicillin allergic: erythromycin for 5-7 days
If symptoms worsen after 2-3 days of taking the above-listed antibiotics → co-amoxiclav
References