GP - Acute otitis media (AOM)

Question 1

What is acute otitis media?

Answer 1

Middle ear infection and inflammation with effusion

Question 2

What age groups does AOM most commonly affect? and why?

Answer 2

Children 4 yrs or less

Due to shorter ETT and enlarged adenoid

Question 3

What are the risk factors for AOM?

Answer 3

• Young age
• Active/ passive smoking
• Frequent contact with other children e.g. daycare or nursery attendance
• Cleft palate
• Use of dummy
• Lack of pneumococcal vaccination
• Prematurity

Question 4

Name 2 bacteria and 2 viruses that cause AOM

Answer 4

Bacteria:

• Haemophilus influenzae
• Streptococcus pneumoniae
• Moraxella catarrhalis

Virus:

• Respiratory syncytial virus (RSV)
• Rhinovirus

(Most cases are viral)

Question 5

How would a patient with AOM normally present with?

Answer 5

Presentations:

Symptoms

• In older children and adults - ear pain
• In younger children - pulling and tugging of the ear + fever + crying + poor feeding + symptoms of URTI (e.g. cough, rhinorrhoea)
  
  • A child who is screaming and distressed may settle quickly if the eardrum perforates + green discharge

Signs/ otoscopic findings

• Red, cloudy, bulging tympanic membrane
• Air-fluid level behind membrane
• Perforated eardrum in severe cases

(Bulging tympanic membrane = AOM; retracted tympanic membrane = OME)

Question 6

How would you manage AOM? (please include any advice you would say to the patient)

Answer 6

Mx:

• Advise that AOM usually lasts about 4 days but can persist up to 1 week. Most cases resolve within 24 hrs
• Advise use of paracetamol/ ibuprofen for pain relief
• Explain that the use of nasal decongestants or antihistamines have little benefits
• Most cases will resolve spontaneously, therefore adopt a No Abx-prescribing strategy/ delayed Abx-prescribing strategy (since most are viral)
• Offer amoxicillin (if allergic, give clarithromycin) immediately if:
  
  • Symptoms last > 4 days and not improving
  • Systemically unwell but don’t require hospital admission
  • Immunocompromise or at high risk of complications secondary to significant heart, lung, kidney, liver or neuromuscular disease
  • Children < 2 yrs old with bilateral AOM
  • Perforation and ear discharge
• If recurrent AOM (>/= 3 AOM episodes in the last 6 months, OR >/= 4 episodes in the last 12 months with at least one episode in the past 6 months) –> grommet insertion

Question 7

When should you admit patients with AOM?

Answer 7

• Admit for immediate specialist assessment for:
  
  • People with a severe systemic infection
  • Complications of AOM e.g. mastoiditis, meningitis, sigmoid sinus thrombosis, brain abscess, facial paralysis
  • Children < 3 months old with a temperature of 38 degree celsius or more
• Consider admitting:
  
  • Children < 3 months old
  • Children 3-6 months old with a temperature of 39 degree celsius or more

Question 8

Perforated eardrum following acute otitis media. How do you treat?

Answer 8

Abx - amoxicillin!