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Otitis media - acute
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Exam Tips
- In OSCEs, a bulging tympanic membrane with effusion is more diagnostic of AOM than erythema alone.
- Differentiate AOM from glue ear: glue ear has effusion and hearing loss but no acute infective pain/fever syndrome.
- State red flags explicitly (post-auricular swelling, focal neurology, severe headache, photophobia, vertigo, facial weakness) and escalate urgently.
- Antibiotics are selective, not routine; delayed prescribing is often appropriate with clear safety-net advice.
- Use weight-based paediatric doses and mention key safety points (no aspirin under 16, NSAID cautions, penicillin allergy checks).
- For image recall, compare normal vs bulging opaque tympanic membrane and perforation with otorrhoea on otoscopy (see standard otoscopy figure sets used in ENT teaching atlases).
Definition
Acute otitis media (AOM) is an acute inflammatory infection of the middle ear, characterized by rapid-onset ear symptoms plus objective middle-ear inflammation and effusion on otoscopy. It is distinct from otitis media with effusion (glue ear), where middle-ear fluid is present without the acute infective syndrome of pain, fever, and a bulging inflamed tympanic membrane.
Pathophysiology
Most episodes follow a viral upper respiratory tract infection that causes eustachian tube dysfunction, negative middle-ear pressure, and fluid accumulation behind the tympanic membrane. This effusion then becomes infected by viruses and/or bacteria (commonly Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Streptococcus pyogenes), producing mucosal inflammation, pus formation, and tympanic membrane bulging. Young children are predisposed because their eustachian tubes are shorter, more horizontal, and functionally immature, which impairs middle-ear ventilation and drainage.
Risk Factors
- Age 6-24 months (especially infancy and preschool years)
- Frequent viral exposure (nursery/daycare attendance, siblings)
- Passive smoke exposure or household smoking
- Not breastfed / formula feeding
- Craniofacial anomalies (for example cleft palate)
- Dummy use and prolonged supine bottle feeding
- Family history of otitis media
- Lack of pneumococcal vaccination
- Prematurity
- Recurrent URTI, gastro-oesophageal reflux, or immunodeficiency
Clinical Features
Symptoms
- Acute ear pain (otalgia), often worse at night
- Fever
- Irritability, crying, poor feeding, sleep disturbance in young children
- Ear tugging/rubbing in preverbal children
- Recent or concurrent coryzal symptoms (cough, rhinorrhoea)
- Otorrhoea if tympanic membrane perforates
- Reduced hearing/fullness
Signs
- Bulging tympanic membrane (most useful diagnostic sign)
- Red, yellow, or cloudy tympanic membrane
- Loss of normal tympanic membrane landmarks
- Middle-ear effusion/air-fluid level
- Perforation with discharge in the external canal
- Reduced tympanic membrane mobility on pneumatic otoscopy
- Red flags of complications: post-auricular swelling/erythema/tenderness, facial weakness, severe headache, photophobia, persistent vomiting, vertigo, nystagmus, altered neurology
Investigations
Clinical otoscopy (first-line, usually sufficient):Bulging, opaque/erythematous tympanic membrane with middle-ear effusion; possible perforation with otorrhoea
Pneumatic otoscopy (if available):Reduced tympanic membrane mobility supports middle-ear effusion
Tympanometry (selected cases/diagnostic uncertainty):Type B (flat) trace suggests middle-ear effusion
Blood tests, ear swab, imaging:Not routine in uncomplicated AOM; consider if severe systemic illness, neonates/young infants, treatment failure, or suspected mastoiditis/intracranial spread
Management
Lifestyle Modifications
- Provide safety-netting: return urgently if worsening, systemic toxicity, or no improvement after about 3 days
- Explain natural history: many improve rapidly; typical course about 3 days (can be up to 1 week)
- Encourage fluids and regular analgesia rather than PRN under-dosing
- No benefit from decongestants or antihistamines for AOM symptom control
- No routine exclusion from school/nursery once fever settles and pain is controlled
- Avoid swimming if tympanic membrane perforation/otorrhoea; air travel may worsen pain
Pharmacological Treatment
Analgesia/antipyretics
- Paracetamol: adults 1 g every 4-6 hours (max 4 g/day); children 3 months-17 years 15 mg/kg per dose every 4-6 hours (max 4 doses in 24 hours)
- Ibuprofen: adults 200-400 mg three times daily with food (max 1.2 g/day OTC; up to 2.4 g/day prescribed); children >=3 months and >=5 kg 5-10 mg/kg per dose three times daily (max 30 mg/kg/day)
Use weight-based dosing in children and avoid alternating regimens unless clinically necessary. Avoid aspirin in under-16s (Reye risk). Ibuprofen cautions: dehydration, renal impairment, active GI ulcer, and NSAID-sensitive asthma.
Antibiotics (when indicated: severe/systemically unwell, high-risk complications, otorrhoea, or <2 years with bilateral AOM; otherwise no or delayed prescription strategy)
- Amoxicillin (first-line): adults and 12-17 years 500 mg three times daily for 5-7 days; children 1 month-11 years 30 mg/kg/day in 3 divided doses (max 1 g three times daily) for 5-7 days
- Clarithromycin (penicillin allergy): adults and 12-17 years 250-500 mg twice daily for 5-7 days; children 1 month-11 years 7.5 mg/kg twice daily (max 500 mg twice daily) for 5-7 days
- Erythromycin (preferred macrolide in pregnancy when macrolide needed): 250-500 mg four times daily or 500 mg twice daily for 5-7 days
Check immediate hypersensitivity history before beta-lactams. Macrolides can prolong QT interval and interact via CYP pathways; review concomitant medicines. Counsel about common adverse effects (GI upset, rash, diarrhoea) and antimicrobial stewardship.
Topical analgesic ear drops (selected patients)
- Phenazone 4% with lidocaine 1% ear drops: short course in older children/adults for pain relief (follow product-specific dosing)
Only use if tympanic membrane is intact (no perforation/otorrhoea, no grommet). Not a substitute for systemic assessment when red flags are present.
Surgical / Interventional
- Urgent ENT/hospital management for suspected mastoiditis, intracranial complications, facial nerve palsy, or severe sepsis
- Myringotomy/tympanocentesis in selected severe, refractory, or diagnostically uncertain cases
- Mastoidectomy plus IV antibiotics if coalescent mastoiditis/abscess
- Consider ventilation tubes (grommets) only in recurrent disease with ongoing burden after specialist assessment
Complications
- Otitis media with effusion (persistent middle-ear fluid)
- Recurrent acute otitis media
- Tympanic membrane perforation (may become chronic if not healed by 3 months)
- Transient conductive hearing loss
- Chronic suppurative otitis media
- Labyrinthitis
- Mastoiditis
- Intracranial infection (meningitis, abscess, venous sinus thrombosis)
- Facial nerve palsy
Prognosis
Prognosis is generally excellent. Even without antibiotics, symptoms improve within 24 hours in many children and most recover within about 3 days; long-term sequelae are uncommon. Recurrent episodes usually reduce with age as eustachian tube anatomy and immune exposure mature.
Sources & References
🏥BMJ Best Practice(1)
✅NICE Guidelines(1)
- Otitis media - acute[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1771)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 44)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 43, 44)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 44)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 214, 215)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 215)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 215)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 591)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 227)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 3055)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 3055, 3056)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 3054, 3055)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2993, 2994)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2543, 2544)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2481, 2482)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2542, 2543)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 379)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 378, 379)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 114)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 114)[context]