Acute otitis media passmed

Question 1

How common is Acute Otitis Media in young children?

Answer 1

Acute otitis media is extremely common in young children, with around half having three or more episodes by the age of 3 years.

Question 2

Describe the pathophysiology of Acute Otitis Media.

Answer 2

Acute otitis media typically follows viral upper respiratory tract infections, which disturb the nasopharyngeal microbiome. This enables bacteria like Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis to infect the middle ear via the Eustachian tube.

Question 3

What are the clinical features of Acute Otitis Media?

Answer 3

Features include otalgia, ear tugging or rubbing by some children, fever in about 50% of cases, hearing loss, and possible ear discharge if the tympanic membrane perforates. Recent viral URTI symptoms are common.

Question 4

What criteria are commonly used to diagnose Acute Otitis Media?

Answer 4

Diagnosis criteria include acute onset of symptoms, otalgia or ear tugging, presence of a middle ear effusion, bulging of the tympanic membrane, otorrhoea, decreased mobility on pneumatic otoscopy, and inflammation of the tympanic membrane.

Question 5

How is Acute Otitis Media managed?

Answer 5

Acute otitis media is generally self-limiting and may not require antibiotics unless symptoms persist, the child is systemically unwell, immunocompromised, or at high risk of complications, or under 2 years old with bilateral conditions. Amoxicillin or, in case of allergy, erythromycin or clarithromycin is prescribed.

Question 6

What are the common sequelae and complications of Acute Otitis Media?

Answer 6

Common sequelae include tympanic membrane perforation leading to otorrhoea and potentially chronic suppurative otitis media if unresolved over 6 weeks. Complications can include mastoiditis, meningitis, brain abscess, and facial nerve paralysis.

Question 7

When should a patient with acute otitis media be admitted to the hospital?

Answer 7

If they have:

Severe systemic infection
Complications (e.g., meningitis, mastoiditis, facial nerve palsy)
Are under 3 months old with a temperature > 38 degrees

Question 8

What is the usual course duration for acute otitis media?

Answer 8

About 3 days but can last up to 1 week.

Question 9

What medications are recommended for pain management in acute otitis media?

Answer 9

Regular doses of paracetamol or ibuprofen.

Question 10

Are decongestants or antihistamines effective in managing acute otitis media?

Answer 10

No, there is no evidence to support their use.

Question 11

What should be advised if no antibiotic prescription is given for acute otitis media?

Answer 11

Most cases will resolve spontaneously. Advise to seek help if symptoms haven’t improved after 3 days or if the child deteriorates clinically.

Question 12

What is a back-up antibiotic prescription for acute otitis media?

Answer 12

Advise that the antibiotic is not needed immediately but should be used if symptoms have not improved after 3 days or if they have worsened significantly at any time.

Question 13

What is an immediate antibiotic prescription for acute otitis media?

Answer 13

Seek medical help if symptoms worsen rapidly or the patient becomes systemically unwell. First-line antibiotic is Amoxicillin for 5-7 days.

Question 14

What antibiotics are recommended for patients with a penicillin allergy?

Answer 14

Clarithromycin or erythromycin.

Question 15

What is the effect of antibiotics on acute otitis media?

Answer 15

Antibiotics marginally reduce the duration of the pain but have no effect on the risk of hearing loss.

Question 16

summarise acute otitis media

Answer 16

Acute otitis media
Acute otitis media is extremely common in young children, with around half of children having three or more episodes by the age of 3 years.

Pathophysiology
whilst viral upper respiratory tract infections (URTIs) typically precede otitis media, most infections are secondary to bacteria, particularly Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
viral URTIs are thought to disturb the normal nasopharyngeal microbiome, allowing bacteria to infect the middle ear via the Eustachian tube

Clinical features and diagnosis

Features
otalgia
some children may tug or rub their ear
fever occurs in around 50% of cases
hearing loss
recent viral URTI symptoms are common (e.g. coryza)
ear discharge may occur if the tympanic membrane perforates

Possible otoscopy findings:
bulging tympanic membrane → loss of light reflex
opacification or erythema of the tympanic membrane
perforation with purulent otorrhoea
decreased mobility if using a pneumatic otoscope

Whilst guidelines vary, the majority use the following criteria to diagnose otitis media:
acute onset of symptoms
otalgia or ear tugging
presence of a middle ear effusion
bulging of the tympanic membrane, or
otorrhoea
decreased mobility on pneumatic otoscopy
inflammation of the tympanic membrane
i.e. erythema

Management

Acute otitis media is generally a self-limiting condition that does not require an antibiotic prescription. There are however some exceptions listed below. Analgesia should be given to relieve otalgia. Parents should be advised to seek medical help if the symptoms worsen or do not improve after 3 days.

Antibiotics should be prescribed immediately if:
Symptoms lasting more than 4 days or not improving
Systemically unwell but not requiring admission
Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
Younger than 2 years with bilateral otitis media
Otitis media with perforation and/or discharge in the canal

If an antibiotic is given, a 5-7 day course of amoxicillin is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given.

Sequelae and complications

Common sequelae include:
perforation of the tympanic membrane → otorrhoea
unresolved with acute otitis media with perforation may develop into chronic suppurative otitis media (CSOM)
CSOM is defined as perforation of the tympanic membrane with otorrhoea for > 6 weeks
hearing loss
labyrinthitis

Complications:
mastoiditis
meningitis
brain abscess
facial nerve paralysis

Management
Admit if:
o Severe systemic infection
o Complications (e.g. meningitis, mastoiditis, facial nerve palsy) o Children < 3 months with a temperature > 38 degrees
Management
 Advise that the usual course of acute otitis media is about 3 days but can last up to 1 week
 Advise regular doses of paracetamol or ibuprofen for pain
 There is no evidence to support the use of decongestants or antihistamines
 Antibiotic prescription management:
o No antibiotic prescription - most cases will resolve spontaneously. Advise to seek help if the symptoms haven’t improved after 3 days or if the child deteriorates clinically o Back-up antibiotic prescription - advise that the antibiotic is NOT needed immediately but should be used if the symptoms have not improved after 3 days or if
they have worsened significantly at any time
o Immediate antibiotic prescription - seek medical help if the symptoms worsen
rapidly or the patient becomes systemically unwell
 Amoxicillin - 5-7 days is first-line
 Penicillin allergy: clarithromycin, erythromycin
 Note: antibiotics marginally reduce the duration of the pain but have no effect on risk of hearing loss

Question 17

Laz summary of acute otitis media

Answer 17

Question 18

An 18-month-old girl is brought to her general practitioner with a three-day history of poor feeding and pulling at their ears. Her observations are as follows:

Respiratory rate of 26 breaths/min
Pulse of 123 beats/min
Temperature of 37.1ºC
Blood pressure of 94/58mmHg
Oxygen saturations of 97%
On examination, you note bulging tympanic membranes with surrounding erythema bilaterally.

What is the appropriate first-line management in this patient?

A delayed prescription of flucloxacillin
Conservative management, ensuring adequate hydration
Immediate prescription of amoxicillin
Immediate prescription of flucloxacillin
Referral to the paediatric assessment unit

Answer 18

Immediate prescription of amoxicillin

If antibiotics are required for otitis media, amoxicillin is first-line
Important for meLess important
The correct answer is an immediate prescription of amoxicillin.

This patient likely has acute bilateral otitis media, as they are younger than two-years-old NICE recommends antibiotic management, the first line being amoxicillin. In patients with penicillin allergy clarithromycin or erythromycin may be used.

A delayed prescription of flucloxacillin is incorrect. Flucloxacillin is useful against B-lactamase producing bacteria. It has good activity against a spectrum of gram-positive and gram-negative bacteria. Flucloxacillin is commonly used to treat impetigo, cellulitis, osteomyelitis, otitis externa, diabetic foot infections and infected leg ulcers.

Conservative management, ensuring adequate hydration is incorrect as this patient meets the NICE criteria for antibiotic prescribing.

Immediate prescription of flucloxacillin is incorrect as this is not the antibiotic of choice in this situation.

Referral to the paediatric assessment unit is incorrect as this patient’s presentation is not suspicious of serious underlying infection and their observations are all within the normal range for her age.