Acute Otitis Media in Children

Question 1

What is acute otitis media?

Answer 1

It is acute inflammation of the middle ear and may be caused by bacteria or viruses.

Question 2

How do infective organisms reach the middle ear and which age group is affected more?

Answer 2

Infecting organisms reach the middle ear from the nasopharynx. Children are particularly vulnerable to the transfer of organisms from the nasopharynx to the ear. As children grow bigger, the angle between the Eustachian tube and the wall of the pharynx becomes more acute, so that coughing or sneezing tends to push it shut. In small children, the less acute angle facilitates infected material being transmitted through the tube to the middle ear.

Question 3

What usually triggers an acute otitis media infection?

Answer 3

Commonly an upper respiratory infection

Question 4

What are the main bacterial pathogens which can cause acute otitis media in children?

Answer 4

The most common bacterial pathogens are Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis and Streptococcus pyogenes.

Question 5

What are the main viral pathogens which can cause acute otitis media in children?

Answer 5

The most common viral pathogens are respiratory syncytial virus (RSV) and rhinovirus.

Question 6

Risk factors for acute otitis media?

Answer 6

• Younger age.
• Male sex.
• Smoking in the household.
• Daycare/nursery attendance.
• Formula feeding - breast-feeding for three months and above has a protective effect.
• Craniofacial abnormalities - eg, Down’s syndrome, cleft palate.

Question 7

Risk factors for recurrent acute otitis media?

Answer 7

• Early first episode.
• Gastro-oesophageal reflux disease (GORD).
• Dummy use.
• Winter season.
• Supine feeding.

Question 8

Symptoms?

Answer 8

AOM commonly presents with acute onset of symptoms:

• Pain (younger children may pull at the ear).
• Malaise.
• Irritability, crying, poor feeding, restlessness.
• Fever.
• Coryza/rhinorrhoea.
• Vomiting.

Question 9

Signs?

Answer 9

• High temperature (febrile convulsions may be associated with the temperature rise in AOM).
• A red, yellow or cloudy tympanic membrane.
• Bulging of the tympanic membrane.
• An air-fluid level behind the tympanic membrane.
• Discharge in the auditory canal secondary to perforation of the tympanic membrane - this may obscure the view completely.
• The pinna may be red.

Children under 6 months of age may display nonspecific symptoms. They may also have co-existing disease such as bronchiolitis, and the tympanic membrane may be difficult to see: it often lies in an oblique position and the ear canal tends to collapse closed.

Question 10

Can perforation of the eardrum help?

Answer 10

Perforation of the eardrum often relieves pain. A child who is screaming and distressed may settle remarkably quickly - and then the ear starts to discharge green pus

Question 11

Diagnosis?

Answer 11

• Usually no investigation is required.
• Culture of discharge from an ear may be indicated in chronic or recurrent perforation or if grommets are present.
• Audiometry should be performed if chronic hearing loss is suspected; however, not during acute infection.
• CT or MRI may be appropriate if complications are suspected.

Question 12

NICE guidance on giving antibiotics?

Answer 12

NICE recommends that children who are systemically very unwell, have symptoms and signs of a more serious illness, or are at higher risk of complications should be offered an immediate antibiotic prescription and advice. Children and young people should be referred to hospital if they have acute otitis media associated with a severe systemic infection, or have acute complications including mastoiditis, meningitis, intracranial abscess, sinus thrombosis or facial nerve paralysis.

Question 13

How often does acute otitis media resolve spontaneously in children?

Answer 13

The majority of cases of AOM will resolve spontaneously. Without specific treatment symptoms improve within 24 hours in 60% of children and settle within three days in 80% of children.

Question 14

Who should be definitely be admitted and who should you consider admitting?

Answer 14

Admit for immediate assessment:

• Children under 3 months of age with a temperature of 38°C or more.
• Children with suspected acute complications of AOM, such as meningitis, mastoiditis, or facial nerve paralysis.

Consider admitting:

• Children who are systemically very unwell.
• Children under 3 months of age.
• Children 3-6 months of age with a temperature of 39°C or more.

Question 15

What antibiotic should be given?

Answer 15

Prescribe a five-day course of amoxicillin.
For children who are allergic to penicillin, prescribe a five-day course of erythromycin or clarithromycin.

If admission or referral is not necessary and the child has been taking a first-line antibiotic, offer a second-line antibiotic:
Prescribe a five-day course of co-amoxiclav.
If allergic to penicillin, check your local guidelines.

If symptoms persist despite two courses of antibiotics, seek specialist advice from an ENT specialist.