Acute Otitis Media

 

This guideline applies to children and adults.

 

In scope: suspected acute otitis media (acute/persistent/recurrent)

Out of scope: other causes of otalgia/otorrhoea

 

Introduction

Many cases of acute otitis media (AOM) are viral. Without antibiotic treatment, symptoms can improve within 24 hours in up to 60% of children^1,2 and most people will recover within 3 days². It can occur in adults but is much more common in children².

It is very common to have temporary lingering symptoms, such as aural fullness, ear sensitivity, aching, pressure, subjective sensation of reduced hearing or imbalance (not true vertigo) for months after an acute infection due to fluid build-up in the middle ear³.

 

Red Flag Features

Features of AOM with²:

• Severe systemic infection/sepsis.
• Local complications, such as:
• Acute mastoiditis – pyrexia, red ear drum, red swelling behind pinna pushing ear forward.
• New facial palsy.
• New and acute-onset true vertigo with nystagmus with or without new sensorineural hearing loss (suggestive of acute bacterial labyrinthitis).
• Petrositis – triad of severe “deep” retro-orbital pain AND abducens (6^th cranial nerve) palsy AND ear discharge.
• Intra-cranial complications, such as venous sinus thrombosis, meningitis or intra-cranial abscess. One of the most sensitive signs is retro-aural headache with very high fever.
• Suspected nasal malignancy.

This list is not exhaustive.

 

Investigations

No investigations are routinely required.

Consider swabbing ear discharge (if present) – particularly if non-resolving following treatment.

 

Management Optimisation

Acute Otitis Media (AOM) – initial presentation:

See NICE CKS: Acute Otitis Media.

 

Persistent AOM (failure to improve or symptoms worsening despite initial / antibiotic treatment):

Consider:

• Red flag features
• Alternative diagnoses e.g. OME (Glue ear) or chronic suppurative otitis media
• If no red flags, consider prescribing an antibiotic

 

Recurrent AOM (recurrent discrete episodes):

• Manage individual episodes as per acute AOM
• Provide advice on preventative measures
• Avoid long-term prophylactic antibiotics – limited benefit and may increase resistant bacteria²
• Consider urgent ENT referral if meets criteria outlined below

 

Advice and Guidance

Refer any suspected nasal malignancy via ENT Advice and Guidance – the consultant will consider the clinical information and advise regarding appropriate prioritisation and urgency of referral.

 

Referral routes

Same-day assessment – straight to ED

Adults (16yr or over) with features of AOM and:

• Severe systemic infection/sepsis
• Suspected intra-cranial complications

 

Same-day assessment – discuss with Paediatric first on-call

Children or adolescents (under 16yr old) with features of AOM and:

• Severe systemic infection/sepsis
• Suspected intra-cranial complications.

 

Same-day assessment – discuss with ENT first on-call

Children and adults with features of AOM and local complications, such as:

• Acute mastoiditis – pyrexia, red ear drum, red swelling behind pinna pushing ear forward.
• New facial palsy.
• New and acute-onset true vertigo with nystagmus with or without new sensorineural hearing loss (suggestive of acute bacterial labyrinthitis).
• Petrositis – triad of severe “deep” retro-orbital pain AND abducens palsy AND ear discharge.

 

Urgent ENT Referral

Inclusion criteria:

• 3 or more discrete episodes of AOM over a 6-month period
• More than 4 discrete episodes of AOM over a 12-month period

Minimum referral information:

• Symptom history of infective events
• Up-to-date examination findings as above.
• Clear information of prior treatment(s) provided, including duration and response
• Confirmation of number of infections experienced to warrant specialist referral, as detailed above

Failure to provide the minimum referral information will result in the referral being returned.

 

Supporting Information

For professionals:

NICE CKS: Acute Otitis Media

Antimicrobial guidelines for primary and community services

NHS Cornwall ICB Treatment Policies

For patients:

Patient UK: Middle Ear Infection

ENT UK: Middle Ear Infections

 

References

1. Antimicrobial guidelines for primary and community services
2. NICE CKS: Acute Otitis Media
3. Johns Hopkins Medicine: Middle Ear Infection in Adults

  

Page Review Information

Review date	13 February 2025
Next review date	13 February 2027
GP speciality lead	Dr Laura Vines
Contributors	Mr Scott Mitchell, Consultant ENT Surgeon