Otitis media

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full CAHS clinical disclaimer

Aim 

To guide PCH ED staff with the assessment and management of otitis media.

Definition

Otitis media is an infection of the middle ear cavity.¹

Background^1,2,3

Otitis media can be divided into 3 separate clinical entities that are managed differently:

1. Acute Otitis Media (AOM)

• This is a common cause of children presenting to a GP or an emergency department
• Peak age is 6-18 months and almost all children have at least one episode
• The underlying cause can be viral, bacterial or both in combination
• Bacterial causes can include Streptococcus pneumoniae, Haemophilus influenza and Moraxella catarrhalis
• The diagnosis of AOM is not always clear, particularly in the infant.

2. Otitis Media with Effusion (Glue Ear)³

• Glue ear is an uncommon presenting complaint in an emergency department as it is usually asymptomatic, although it can cause balance issues
• It may be found as part of a routine assessment, although it is not readily diagnosed without tympanometry or pneumotoscopy
• Glue ear is a common problem in young children that follows acute otitis media, is largely self-resolving and needs no intervention
• It can cause conductive hearing loss which can lead to speech and language delay or balance problems
• It is usually diagnosed with tympanometry or pneumotoscopy
• Assessment of hearing by formal audiology is indicated for persistent glue ear (beyond 3 months) or if there are other indications, such as parental concern about hearing.

3. Chronic Suppurative Otitis Media⁴

• This is defined as a chronic discharging otitis media (for at least 6 weeks) with perforated eardrum
• It is a less common complication of AOM, or a recurrent problem in some children with either a chronic perforation or a grommet.
• There is a copious, non-painful, white, yellow or green discharge, with no evidence of ear canal inflammation.
• It is often difficult to treat and if not of a very recent onset usually contains multi-resistant organisms such as Pseudomonas or Proteus species.

Risk factors and At-Risk Groups

• Low socio-economic status
• Aboriginal and Torres Strait Islander
• Immunocompromised
• Down syndrome
• Other risk factors may include cigarette smoking and attending day care⁴

Assessment¹

• Otoscopy must be performed in all children
• No investigations are required.

History

Acute Otitis Media¹

• The child will present with an acute onset of a painful ear and fever, often following a prodrome of an upper respiratory tract infection
• A younger child may present more non-specifically with fever, crying / screaming / unsettled and possibly vomiting

Otitis Media with Effusion (Glue Ear)³

• Usually asymptomatic but can cause balance issues
• There is no pain

Chronic Suppurative Otitis Media

• Non painful copious discharge from the ear⁴

Examination

Acute Otitis Media¹

• Middle ear effusion (dull or opaque, bulging tympanic membrane, air-fluid level, otorrhoea)
• Significant erythema of the tympanic membrane
• There may be other signs of an upper respiratory tract infection: coryza, cough, erythematous pharynx or tonsils
• A mildly red ear drum with no pain should not lead to a diagnosis of otitis media
• There may be perforation of the tympanic membrane and otorrhoea (purulent), which will relieve the pain

Otitis Media with Effusion (Glue Ear)

• Fluid behind the tympanic membrane, best diagnosed by tympanometry or pneumotoscopy³

Chronic Suppurative Otitis Media⁴

• Discharge from the ear canal with no evidence of inflammation
• Usually copious, non-painful, white, yellow or green discharge.

Investigations

• Ear swabs are not required.¹

Management

• First-line management of AOM is supportive with simple oral analgesia (e.g. paracetamol, ibuprofen)
• Consider topical anaesthetic drops (Auralgan).⁵
• Consider topical antibiotic ear drops (e.g.: Ciproxin HC®).⁵
• Oral antibiotics should only be used initially in high-risk children:⁵
  • Infants younger than 6 months
  • Children younger than 2 years with bilateral infection
  • Aboriginal and Torres Strait Islander children
• Antibiotics are not indicated for low-risk children, the evidence suggests that this only shortens the duration of ear pain by one day, does not reduce the complication rate, and contributes to antibiotic resistance in the community⁵ Refer to Ear, Nose, Throat and Dental Infections: Paediatric Empiric Guidelines - ChAMP Guideline

Referrals and follow-up

• Children with recurrent episodes of acute otitis media, otitis media with effusion or chronic suppurative otitis media should be referred to an Audiologist and an Ear Nose and Throat Surgeon for further assessment^{2, 3, 4}
• Investigations may include audiology, tympanometry and pneumatoscopy^{3, 4}
• Children can be considered for grommet insertion +/- adenoidectomy^{3, 4}
• Referral to a Speech Pathologist for speech and language assessment may also be required^{3, 4}
• Refer to Ear, Nose, Throat and Dental Infections: Paediatric Empiric Guidelines - ChAMP Guideline

References

1. Wald ER. Acute otitis media in children: Clinical manifestations and diagnosis. UpToDate. [Last updated April 2022. Cited: 3 November 2022]. Available from: https://www-uptodate-com.pklibresources.health.wa.gov.au/contents/acute-otitis-media-in-children-clinical-manifestations-and-diagnosis?search=acute otitis media in children treatment&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3 https://www-uptodate-com.pklibresources.health.wa.gov.au/contents/acute-otitis-media-in-children-clinical-manifestations-and-diagnosis.http://www.uptodate.com/
2. Pelton SI & Tähtinen P. Acute otitis medica in children: Epidemiology, microbiology and complications. UpToDate. [Last updated April 2022. Cited: 3 November 2022]. Available from: https://www-uptodate-com.pklibresources.health.wa.gov.au/contents/acute-otitis-media-in-children-epidemiology-microbiology-and-complications.http://www.uptodate.com/
3. Pelton SI & Marom T. Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis. UpToDate. [Last updated April 2021. Cited: 3 November 2022]. Available from: https://www-uptodate-com.pklibresources.health.wa.gov.au/contents/otitis-media-with-effusion-serous-otitis-media-in-children-clinical-features-and-diagnosis.http://www.uptodate.com/
4. Levi JL & O’Reilly RC. Chronic suppurative otitis media (CSOM): Clinical features and diagnosis. UpToDate. [Last updated February 2022. Cited: 3 November 2022]. Available from: https://www-uptodate-com.pklibresources.health.wa.gov.au/contents/chronic-suppurative-otitis-media-csom-clinical-features-and-diagnosis.http://www.uptodate.com/
5. Pelton SI & Tähtinen P. Acute otitis media in children: Treatment. UpToDate. [Last updated October 2022. Cited: 3 November 2022]. Available from: https://www-uptodate-com.pklibresources.health.wa.gov.au/contents/acute-otitis-media-in-children-treatment.http://www.uptodate.com/

Endorsed by:	Nurse, Co-Director, Surgical Services	Date:	Feb 2023
		Review date:	Jan 2026

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