Acute Otitis Media

Question 1

Acute otitis media is most common in…

Answer 1

Children

Question 2

The eustachian tube is the connection between…

Answer 2

The eustachian tube is the connection between the middle ear and the nasopharynx

Question 3

The middle ear cleft is made up of the … air cells posterior to the middle ear cavity, the … tube and the nasopharynx.

Answer 3

The middle ear cleft is made up of the mastoid air cells posterior to the middle ear cavity, the eustachian tube and the nasopharynx.

Question 4

Acute otitis media mainly occurs in children and is a result of dysfunction of the …

Answer 4

Acute otitis media mainly occurs in children and is a result of eustachian tube dysfunction. If the eustachian tube does not work otitis media can develop. For example infection or reaction in middle cleft can result in oedema of the eustachian tube, similarly adenoid hypertrophy from an infection can block eustachian tube drainage and pressure equalisation resulting in negative pressure in the middle ear.

Question 5

Otitis media is more common in children - why?

Answer 5

Otitis media is more common in children precisely because of the anatomical difference of the eustachian tube between children and adults. Unlike adults eustachian tube, a childs’ Eustachian tube is more shorter, horizontally aligned, softer and has a smaller passageway. This allows for easier spread of infection from the nasopharynx to the middle ear.

Question 6

Acute otitis media - how long does it usually affect people?

Answer 6

3 days - 1 week
Usually self limiting - majority do not require antibiotics

Question 7

Peak incidence of otitis media

Answer 7

0 to 4 years, peak = 9-15 months

Question 8

Diagnosing acute otitis media

Answer 8

Otoscopy

Question 9

Symptoms of acute otitis media in neonates

Answer 9

Irritability
Difficulty feeding
Fever

Question 10

Symptoms of acute otitis media in young children

Answer 10

Holding or tugging ear
Irritability
Fever

Question 11

Symptoms of acute otitis media in older children + adults

Answer 11

Otalgia (ear pain)
Hearing loss
Fever

Question 12

Tympanic membrane view

Answer 12

Otoscopy is key to identifying signs of AOM. It allows for visualisation of the tympanic membrane, behind which the middle ear lies. The normal tympanic membrane has a slight translucency with a colour sometimes described as pearly-grey. The malleus (the first of the three bones of the middle ear) is clearly visible.

Question 13

Acute otitis media - NICE CKS advise the following patients are considered for admission:

Answer 13

Children younger than 3 months of age.
Children 3–6 months of age with a temperature of 39°C or more.

Question 14

NICE CKS advise the following patients should be admitted for treatment:

Answer 14

People with a severe systemic infection.
People with suspected acute complications of acute otitis media (AOM), such as meningitis, mastoiditis, intracranial abscess, sinus thrombosis or facial nerve paralysis.
Children younger than 3 months of age with a temperature of 38°C or more.

Question 15

Antibiotics and acute otitis media

Answer 15

As described above, most cases of AOM are self-limiting. Overuse of antibiotics risks both adverse effects for the patient and increasing antibiotic resistance. There are three main approaches for antibiotic prescribing in AOM:

No antibiotics
Delayed prescription
Immediate antibiotics

Question 16

Antibiotics - AOM

Answer 16

Where antibiotics are indicated, amoxicillin tends to be preferred first-line (in absence of penicillin allergies) as a 5-7 day course, with alternatives including clarithromycin and erythromycin. Co-amoxiclav (combination of amoxicillin and clavulanic acid) is used second line (again in the absence of penicillin allergies) in treatment-resistant cases.

Question 17

If nasopharyngeal cancer is suspected an urgent referral to ENT is required. In particular, NICE CKS advises high suspicion if:

Answer 17

Persistent symptoms and signs of otitis media with effusion in between episodes (for example, conductive hearing loss) due to obstruction of the eustachian tube orifice.
Persistent cervical lymphadenopathy (usually in the upper levels of the neck).
Epistaxis and nasal obstruction.

Question 18

Frequent complications of acute otitis media:

Answer 18

Persistent AOM
Recurrent AOM
Perforation of tympanic membrane
Hearing loss

Question 19

Mastoiditis after AOM

Answer 19

Mastoiditis is perhaps the most commonly occurring serious complication. It is a potentially life-threatening infection of the mastoid air cells causing pain, swelling and erythema behind the ear and systemic upset. It tends to affect younger patients, normally under the age of 5. Blood tests, fluid cultures and CT scanning form the core of the work-up. It requires prompt recognition, early antibiotics and management that may include myringotomy (drain the middle ear with a hole in the tympanic membrane) and mastoidectomy (removal of infected tissue/bone).