Background Information
Aetiology
AOM can be caused by both bacteria and viruses, commonly both are present at the same time.
Most common bacterial pathogens:
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
- Streptococcus pyogenes
Viral pathogens associated with AOM:
- Respiratory syncytial virus
- Rhinovirus
- Adenovirus
- Influenza virus
- Parainfluenza virus
Risk Factors
- Young
- 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
Guidelines
Investigation and Diagnosis
Clinical diagnosis.
Acute onset of symptoms:
- Otalgia
- Younger children: ear tugging / rubbing / holding
Otoscopic examination findings:
- Red / yellow / cloudy tympanic membrane
- Bulging tympanic membrane
- Tympanic membrane perforation and/or discharge in the external auditory canal
Clinical features that are NOT suggestive of AOM:
- Non-bulging tympanic membrane
- Air-fluid level without bulging tympanic membrane
These findings are more suggestive of middle ear effusion (glue ear).
Management
General Advice / Conservative Management
Advise patients:
- The usual course of AOM is usually ~3 days, but can be up to 1 week
- No need to restrict from usual daily activities
- Avoid swimming if there is tympanic membrane perforation
- Ear pain may worsen with air travel
- Children may return to school / day care once fever and otalgia have resolved
Symptomatic management:
- Paracetamol or ibuprofen
- Consider ear drops (phenazone + lidocaine) for pain
- Only if antibiotics not given AND no tympanic membrane perforation
Antibiotic Therapy
Indications for Antibiotics
Indications for immediate antibiotic prescription:
- Systemically unwell
- Features of more serious illness / conditions
- 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 noted that both viral and bacterial infections causing AOM are usually self-limiting and do not routinely require antibiotics.
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
References