Acute Otitis Media Clinical Overview

Written By Danial Mirza

I. The "On-Call" Snapshot

  • Clinical Significance in Malaysia: This is one of the most common reasons a child gets a prescription for antibiotics in our clinics and ED. Misdiagnosing it leads to unnecessary antibiotic use, and missing it can lead to complications.

  • High-Yield Definition: Acute Otitis Media is the rapid onset of signs and symptoms of inflammation in the middle ear, which is characterised by the presence of a middle ear effusion (MEE). (Sourced from UpToDate and American Academy of Pediatrics Guidelines).

  • Clinical One-Liner: Basically, it's a bacterial or viral infection causing pus and pressure to build up behind the eardrum, typically after a cold.

II. Etiology & Risk Factors

  • Etiology: Most commonly triggered by a viral Upper Respiratory Tract Infection (URTI) that leads to Eustachian tube dysfunction. This causes fluid to get trapped, which then gets superinfected by bacteria.

    • Common Bacterial Pathogens: Streptococcus pneumoniae, Non-typeable Haemophilus influenzae, Moraxella catarrhalis.

  • Risk Factors:

    • Non-modifiable:

      • Age (Peak incidence 6-18 months)

      • Male gender

      • Craniofacial abnormalities (e.g., Down's syndrome, cleft palate)

      • Family history

    • Modifiable:

      • Daycare attendance

      • Lack of breastfeeding

      • Use of pacifiers

      • Supine feeding (bottle propping)

      • Exposure to tobacco smoke (passive smoking)

III. Quick Pathophysiology

A URTI causes inflammation and oedema of the nasopharyngeal mucosa, including the Eustachian tube opening. The tube gets blocked. This leads to negative pressure in the middle ear, causing fluid to be drawn in from the surrounding mucosa, creating a sterile effusion. Nasopharyngeal bacteria then travel up the tube into this stagnant fluid and multiply, leading to suppuration, inflammation, and a bulging, painful tympanic membrane (TM).

IV. Clinical Assessment

  • Red Flags & Immediate Actions:

    • Toxic-looking, septic child (lethargy, poor perfusion, high fever) → Alert senior immediately, start sepsis workout, get IV access.

    • Postauricular swelling, erythema, or protrusion of the pinna → Suspect mastoiditis. Alert senior, for urgent ENT consult.

    • Facial nerve palsy (asymmetrical facial movement) → Suspect complication. Alert senior, for urgent ENT consult.

    • Signs of meningism (neck stiffness, photophobia) → Suspect intracranial spread. Urgent senior review.

  • History:

    • Common (>50%): Preceding URTI symptoms (cough, coryza), otalgia (ear pain; seen as ear pulling/tugging in pre-verbal child), fever, irritability/excessive crying.

    • Less Common (10-50%): Otorrhoea (if TM perforates), poor feeding, vomiting, diarrhoea, poor sleep.

    • Pertinent Negatives: Ask about and document the absence of red flag symptoms, no previous episodes (to rule out recurrent AOM), and no hearing concerns (to differentiate from OME).

  • Physical Examination:

    • General: Assess for toxicity, hydration status, and work of breathing.

    • Otoscopy is key: You must be able to handle an otoscope.

      • Hallmark Sign: A bulging, erythematous (red) tympanic membrane with loss of landmarks (e.g., handle of malleus is obscured).

      • Other findings: May see an air-fluid level or bullae on the TM. A cloudy, opaque TM is also significant. Pneumatic otoscopy (if you have one and know how to use it) will show reduced or absent mobility of the TM.

      • Important: A red TM alone is NOT AOM. A crying child can have a flushed, pink TM. You need bulging or clear signs of effusion.

  • Clinical Pearl: Don't promise a parent that antibiotics will make their child feel better in a few hours. The most important first step is pain relief. Paracetamol and ibuprofen are your best friends here.

V. Diagnostic Workflow

  • Differential Diagnosis:

    • Otitis Media with Effusion (OME):

      • Points For: Fluid in the middle ear is present.

      • Points Against: No acute inflammation. The child is usually well, without fever or severe pain. TM is retracted or neutral, not bulging.

      • How to Differentiate: Clinical history (no acute symptoms) and otoscopy (no bulging/erythema).

    • Otitis Externa (OE):

      • Points For: Ear pain, otorrhoea.

      • Points Against: Pain is worsened by pulling the pinna or pressing on the tragus. Discharge is often present from the start.

      • How to Differentiate: Examination shows an inflamed external auditory canal. The TM may be normal if you can see it.

    • Viral URTI with referred pain:

      • Points For: Fever, irritability, red TM from crying.

      • Points Against: Normal TM landmarks, no bulging, normal TM mobility on pneumatic otoscopy.

      • How to Differentiate: A good otoscopic exam is the only way.

  • Investigations Plan:

    • Bedside / Initial: None. This is a clinical diagnosis.

    • First-Line Labs & Imaging: Not indicated for uncomplicated AOM.

    • Confirmatory / Gold Standard: Tympanocentesis (aspirating middle ear fluid) is the gold standard but is reserved for severe/refractory cases by the ENT team. Your gold standard is a confident clinical diagnosis with otoscopy.

VI. Staging & Severity Assessment

We base our management on severity and age. This is adapted from international guidelines and is the standard of care.

  • Severe AOM:

    • Moderate to severe otalgia, OR

    • Otalgia for >48 hours, OR

    • Temperature ≥ 39°C.

  • Non-Severe AOM:

    • Mild otalgia AND

    • Duration <48 hours AND

    • Temperature < 39°C.

  • Impact on Management:

    • Children < 6 months old: Always treat with antibiotics.

    • Children 6 months - 2 years: Treat with antibiotics.

    • Children > 2 years with Severe AOM: Treat with antibiotics.

    • Children > 2 years with Non-Severe AOM: Can offer parents a choice between immediate antibiotics or a "watchful waiting" period of 48-72 hours with analgesia, and starting antibiotics only if symptoms do not improve or worsen.

VII. Management Plan

  • Immediate Stabilisation (The ABCDE Plan):

    • This is rarely needed unless the child is septic.

    • The most immediate action is pain relief:

      • Paracetamol: 15 mg/kg per dose, QDS/TDS.

      • Ibuprofen: 10 mg/kg per dose, TDS (for children >6 months old). Can be alternated with Paracetamol.

  • Definitive Treatment (The Ward Round / Clinic Plan):

    • First-Line (Antibiotic of choice):

      • Syrup Amoxicillin: High dose at 80-90 mg/kg/day, divided into two doses (BD). This is to overcome potential S. pneumoniae resistance.

      • Duration: 5-7 days for children >2 years with mild/moderate disease. 10 days for children <2 years or those with severe disease.

    • Second-Line (If failed first-line after 48-72h, or recent Amoxicillin use):

      • Syrup Co-amoxiclav (Augmentin): Dosed based on the amoxicillin component (80-90 mg/kg/day) divided BD. Be mindful of the higher rate of diarrhoea.

    • For Penicillin Allergy (Non-anaphylactic):

      • Consider a cephalosporin like Cefuroxime.

  • Long-Term & Discharge Plan:

    • Advise parents to complete the course of antibiotics if prescribed.

    • Explain the importance of analgesia.

    • Advise on risk factor modification (e.g., smoking cessation in the household).

    • Follow-up is not routinely needed for a first uncomplicated episode.

    • Advise to return if symptoms worsen, do not improve in 48-72 hours, or if red flags develop.

VIII. Complications

  • Intratemporal (within the ear structures):

    • TM Perforation: Management: Usually heals spontaneously. Keep the ear dry.

    • Mastoiditis: Management: IV antibiotics, urgent ENT consult, may require surgery.

    • Chronic Suppurative Otitis Media (CSOM): Management: ENT referral.

    • Hearing Loss (Conductive): Management: Usually transient; if persistent OME develops post-AOM, may need ENT follow-up.

  • Intracranial (Rare but serious):

    • Meningitis, Brain Abscess: Management: Medical emergency requiring IV antibiotics, PICU admission and neurosurgical input.

IX. Prognosis

  • Excellent. Most cases resolve without any complications.

  • Spontaneous resolution without antibiotics occurs in about 80% of cases (especially non-severe).

  • Prognostic Factors for Recurrence:

    • First episode before 6 months of age.

    • Daycare attendance.

    • Parental smoking.

X. How to Present to Your Senior

"Dr., for your review please. This is [Patient Name], a [Age] boy/girl in the outpatient clinic, who presented with a 2-day history of fever and tugging at the right ear, following a cold. On otoscopy, the right tympanic membrane is bulging and erythematous with loss of landmarks. My diagnosis is Acute Otitis Media. Based on his age and high fever, I believe this is severe AOM requiring antibiotics. I plan to start high-dose Syrup Amoxicillin and have already advised the mother on Paracetamol and Ibuprofen for pain. I would like your opinion on the management plan."

XI. Summary & Further Reading

  • Top 3 Takeaways:

    1. AOM is a clinical diagnosis based on a bulging, inflamed TM; a red TM alone is not enough.

    2. Management priority is effective analgesia (Paracetamol/Ibuprofen).

    3. Use a stratified approach for antibiotics: treat infants and severe cases immediately; consider watchful waiting in older children with non-severe disease.

  • Key Resources:

Danial Mirza
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Otitis Media with Effusion Clinical Overview
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CSOM Clinical Overview