Otitis media

Overview

•Otalgia - unilateral; in pre-verbal children may manifest as ear-tugging, irritability, or disturbed sleep

•Fever - high fever (>38.5°C) suggests more severe infection

•Otorrhoea - purulent discharge indicates TM perforation; pain often improves as pressure is relieved

•Conductive hearing loss - due to middle ear fluid; usually temporary

•Otoscopy - bulging TM, loss of light reflex, erythema, reduced mobility on pneumatic otoscopy

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A bulging tympanic membrane with loss of the light reflex is the most reliable otoscopic sign of AOM. Erythema alone is insufficient - a crying child can redden the TM without infection.

Management

•Watchful waiting + analgesia (*paracetamol / ibuprofen - first approach for most patients; majority resolve within 2-3 days

•NICE indications for immediate antibiotics - prescribe if ANY of the following:

•Child under 2 years with bilateral AOM - higher risk of complications regardless of temperature or systemic wellness

•Otorrhoea (discharge) - indicates TM perforation

•Systemically very unwell / signs of sepsis

•Symptoms not improving after 4 days of watchful waiting

•High risk of complications - immunocompromised, craniofacial abnormalities, cochlear implants

•First-line antibiotic: amoxicillin 5-7 days (oral)

•Penicillin allergy: clarithromycin or erythromycin

•No improvement after 2-3 days on amoxicillin: switch to co-amoxiclav (covers beta-lactamase-producing H. influenzae and M. catarrhalis)

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Aminoglycoside-containing ear drops (e.g. neomycin, gentamicin) are CONTRAINDICATED when the TM is perforated - aminoglycosides are ototoxic and reach the cochlea through the perforation, risking permanent sensorineural hearing loss. Use oral antibiotics instead.

Complications

•Mastoiditis - most common serious complication; post-auricular tenderness, swelling, pinna displaced anteroinferiorly; requires same-day ENT assessment and IV antibiotics or surgical drainage

•Cholesteatoma - abnormal keratinising squamous epithelium; causes bone erosion; surgical emergency if it reaches ossicles or inner ear

•Intracranial spread - meningitis, brain abscess, lateral sinus thrombosis; suspect if severe headache, neck stiffness, or focal neurology

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Mastoiditis red flags: post-auricular erythema/swelling/fluctuance, anteroinferiorly displaced pinna, fever not settling with antibiotics - require same-day ENT assessment.

Tympanic membrane perforation

•Most infective/traumatic perforations heal spontaneously within 6-8 weeks

•Advise: keep ear dry (no swimming, cotton wool plug in shower), avoid forceful nose-blowing

•Review at 6-8 weeks - refer to ENT if perforation has not healed by this point

Otitis media with effusion (glue ear)

•Chronic, non-infective fluid collection behind an intact TM - most common cause of acquired conductive hearing loss in children

•Majority resolve spontaneously within 3 months - no intervention required initially

•If hearing loss persists beyond 3 months and is significant (typically >25 dB) - refer for consideration of grommets

•Autoinflation with Otovent balloon may be tried in older cooperative children