Otitis media in children

Question 1

Features and cause

Answer 1

Two peaks of incidence:

• 6–12 mths of age
• school entry

Seasonal incidence coincides with URTIs.

The commonest organisms are:

1. viruses

• adenovirus
• enterovirus

2, bacteria

• S. pneumoniae
• H. influenzae
• Moraxella catarrhalis

Question 2

Symptoms

Answer 2

Fever, irritability, otalgia and otorrhoea may be present.

The main symptoms in older children are increasing earache and hearing loss.

Pulling at the ears is a common sign in infants.

Viral cause indicated by reddening and dullness of tympanic membrane (without mucopus) associated with URTI.

Question 3

Examination

Answer 3

Bacterial OM is suggested by acute onset of ear pain/tugging, hearing loss, irritability and fever.

Suppurative OM has progressive erythema and bulging of OM with loss of landmarks ± vomiting.

Question 4

Treatment

Answer 4

Rest patient in warm room with adequate humidity

Paracetamol suspension for pain (high dosage)

Decongestants only if nasal congestion

Antibiotics not warranted for viral causes, most improve within 48 hrs.

Question 5

Possible clinical indications for antibiotics in children with painful otitis media

Answer 5

Consider immediate treatment:

• acute OM in the only hearing ear
• risk of complications in those at risk, e.g. cochlear implant

Other considerations:

• < 2 years with bilateral otitis media
• Sick child with fever
• Vomiting
• Red–yellow bulging TM
• Loss of TM landmarks or perforation TM
• Persistent fever and pain after 48 hours conservative approach

Question 6

For bacterial OM the antibiotic of choice is:

Answer 6

• amoxycillin 15 mg/kg (to max. 500 mg) (o) tds for 5 d

or

• amoxycillin 30 mg/kg bd for 5 d (for compliance)

If β-lactamase producing bacteria are suspected or documented or initial treatment fails, use:

• cefaclor 12.5 mg/kg (to max. 250 mg) (o) tds for 5–7 d (cefaclor is second choice irrespective of cause) or
• (if resistance to amoxycillin is suspected or proven) amoxycillin/potassium clavulanate or cefuroxamine

Question 7

Follow-up:

Answer 7

report if no improvement in 72 h

re-evaluate at 10 d

Question 8

Complications

Answer 8

Middle-ear effusion:

• an effusion up to 2 mths is relatively normal and antibiotics not warranted.
• If the effusion persists beyond 3 mths refer for an ENT opinion.

Acute mastoiditis:

• pain, swelling and tenderness developing behind the ear with deterioration of the child
• requires immediate referral

Chronic suppurative otitis media

Question 9

Recurrent acute otitis media (AOM)

Answer 9

Prevention of AOM is indicated if it occurs at least 3 episodes in 6 months or for ≥4 episodes in 12 mths.

Chemoprophylaxis (for about 4 mths) amoxycillin 20 mg/kg (o) bd or cefaclor bd

Check pneumococcal vaccination.