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Acute otitis media – Emergency

Acute otitis media – Emergency management in children

Key points

  • A diagnosis of AOM should be considered in any young child who presents with irritability, lethargy, otorrhoea and fever with or without localised ear pain.
  • Diagnosis is routinely based on symptoms and otoscopy findings.
  • Primary treatment is aimed at reducing pain.
  • Symptoms in isolated, unilateral AOM usually resolve after 2 days without antibiotic treatment.
  • Always consider the possibility of sepsis in an unwell child with a fever.

Purpose

This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with symptoms of acute otitis media (AOM) in Queensland.

This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from senior staff in Infectious Diseases, ENT and Pharmacy, Lady Cilento Children’s Hospital, Brisbane. It has been endorsed for use across Queensland by the Statewide Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Division.

Introduction

AOM is a rapid onset active infection of the middle ear, characterised by otalgia (earache), irritability and fever.1 It is a common problem with 66% of children having an episode by 3 years of age, and 90% having at least one episode by 6 years.2,3

AOM is primarily a result of a dysfunctioning eustachian tube. In a viral upper respiratory tract infection, physical and immunologic changes in the nasopharynx allow the normal bacterial colonizers (commonly Streptococcus pneumonia, Haemophilus influenza, and Moraxella catarrhalis)3,4 to enter the eustachian tube. The anatomy of the eustachian tubes (short, wide, straight and relatively horizontal plane)5 in infants and young children predisposes them to infection. The aetiology can be either bacterial (estimated to be 27%), viral (<5%) or a combination of bacterial and viral (66%).4,6

Risk factors for recurrent otitis media include:

  • exposure to cigarette or wood smoke
  • day care attendance
  • use of a dummy
  • Indigenous or Torres Strait Islander background
  • short duration of breastfeeding.7,8

Most cases resolve without complications. Tympanic membrane perforation presents as discharge from the ear with relief of pain and occurs as a complication of AOM in approximately 7% of cases.9 Spontaneous healing occurs in > 90% of cases.10 Chronic suppurative otitis media is described as persistent perforation with draining exudate for > 6 weeks.

Rare but serious complications of AOM include mastoiditis, meningitis, lateral sinus thrombosis and facial nerve palsy.11

Assessment

There is no gold standard for the diagnosis of AOM.1  Pain is the major symptom of AOM but the diagnosis should be considered in any child who presents with irritability, lethargy, otorrhoea and fever, with or without localised ear pain. Infants may present with feeding difficulties.

  • ALERT – Always consider the possibility of sepsis and do not accept AOM as lone focus of fever in sick febrile child.

History

History should include specific information on:

  • pain (including location and onset)
  • discharge from the ear
  • behaviours such as rubbing or tugging at ear
  • history of fever and use of anti-pyretics
  • systemic symptoms
  • previous ear infections

Examination

Otoscopy

Otoscopy is the most important examination procedure in the diagnosis of AOM. Parental assistance can help ensure adequate immobilisation of the child and improve visualisation of the tympanic membrane. Most parents feel comfortable holding the child in their arms with the head held resting against the parent’s shoulder or chest and holding the child’s arms.

Holding a child during an ear exam

Source: 2012 UpToDate in Pediatrics ‘Holding a child during an ear exam12

The auditory canal and tympanic membrane should be assessed for:

  • presence or absence of discharge
  • position of tympanic membrane (neutral, retracted or bulging)
  • colour
  • translucency
  • mobility
  • perforation

Acute otitis media

Source: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th Ed.13

One of the challenges in diagnosis of AOM and otoscopy is differentiating between the effusion seen in AOM and that seen in otitis media with effusion (OME). OME is also known as “glue ear”, and is a collection of non-purulent fluid (effusion) in the middle ear. It is usually seen as a result of AOM, is often asymptomatic, and if persists can lead to hearing impairment.

Differentiating AOM from OME
AOM OME
Tympanic membrane is usually bulging

Tympanic membrane is typically red, white or pale yellow

Tympanic membrane is usually retracted or in the neutral position

Tympanic membrane is typically amber or blue

A fluid level or bubbles may be seen behind the tympanic membrane

Clinical diagnosis of AOM requires ALL of the following:

  • onset <48 hours
  • redness and bulging of the tympanic membrane (middle ear inflammation)
  • middle ear effusion

Redness of the tympanic membrane alone is not suggestive of AOM. Redness can also be caused by many other processes including crying, fever, URTI and trauma.

Serious complications of AOM
Complication Incidence Presentation
Mastoiditis

(infection spreads from the middle ear to the nearby mastoid air cells)

1:1000 cases of AOM in developed countries14, but more common in indigenous children1 May present with fever, ear pain, retro-auricular swelling and/or erythema with mastoid tenderness. The affected ear may be pushed forward and downward.
Facial nerve palsy < 1 per 100, 000 cases of AOM Unilateral facial droop of lower motor neurone type.
Intracranial complications such as meningitis, brain abscess, subdural empyema 

(caused by direct bacterial invasion from the middle ear and mastoid, or haematogenous spread to the intracranial space)

Rare AOM plus fever, headache, vomiting, irritability, or altered conscious state, with or without focal neurologic signs.14
Sepsis Rare Toxic
  • Seek urgent ENT advice if any serious complications of AOM are suspected.

Investigations

As AOM is a clinical diagnosis, investigations are not routinely recommended.

Tympanocentesis (to obtain middle ear fluid for culture) should only be performed by an ENT surgeon and is usually not required since antimicrobial therapy (if indicated) should be started empirically.

Where there is AOM with perforation, a bacterial swab from the ear canal should be taken if there is reason to suspect resistant organisms (e.g. failure of initial antibiotic treatment).

Management

Refer to the flowchart for a summary of the recommended emergency management of a child presenting with symptoms suggestive of AOM.

Pain relief

Acute otitis media is a painful condition and oral analgesics should be used early to minimise pain.

Analgesia dosing for the management of acute otitis media in children
Analgesic Dose
Paracetamol (PO) Age over 3 months: 15mg/kg/dose (maximum 1g) every four hours, maximum 4 doses in 24 hours
Ibuprofen (PO) Age over 3 months: 10mg/kg/dose (maximum 400mg) every six to eight hours, maximum three doses in 24 hours
Oxycodone (PO) 0.1mg/kg/dose (max 10mg) orally every 4 hours when required

Antibiotic therapy

Antibiotics do not alter the course for most children with mild, uncomplicated AOM.15 Without antibiotic treatment, pain resolves after 24 hours in 60% of children, and most infections resolve spontaneously within 7 days. There is evidence that antibiotics may reduce the risk of TM perforation or AOM in the contralateral ear, however the incidence of side effects such as vomiting, diarrhoea and rash is increased. There is insufficient evidence to determine if antibiotic use reduces the risk of mastoiditis or meningitis.15

The recommended approach for mild uncomplicated AOM is to defer the use of antibiotics for 24-48 hours, and proceed to antibiotics only if symptomatic after this time. Antibiotics may then be initiated following clinical review or at the parent’s discretion (if provided with a script at the initial consultation). Evidence suggests relying on parental assessment reduces antibiotic usage by up to two thirds with equivalent parental satisfactions rates when compared to early antibiotic treatment.

Most children with isolated unilateral AOM do not require antibiotic treatment.

Initial antibiotic therapy is recommended for all children with systemic features (defined as fever > 39°C, vomiting and lethargy).

Consider initial antibiotic treatment for the following children:

  • age < 6 months
  • age < 2 years with bilateral acute otitis media
  • symptoms > 48 hrs
  • severe symptoms (fever > 39°C and moderate to severe otalgia)
  • evidence of perforation (purulent otorrhoea or perforation visualised)
  • those at higher risk of complications (such as chronic suppurative otitis media or mastoiditis) including the following children:
    • Indigenous or Torres Strait Islander background
    • immunocompromised
    • uncertain access to follow-up

Refer to the CHQ Antibiocard (outlined below) or local protocols for antibiotic therapy recommendations.

Antibiotics for the treatment of acute otitis media in children
Antibiotic Dose
Amoxycillin (PO) 25mg/kg/dose (maximum 1000 mg) 8-hourly for 5 days OR

If suspect non-compliance:

45mg/kg/dose orally (maximum 1000mg) 12-hourly for 5 days

Amoxycillin +clavulanate (PO) Broadened cover with Amoxycillin + clavulanate should be considered for children:

  • who have an inadequate response within 48-72 hours of Amoxycillin (to cover against beta-lactamase producing strains of Haemophilus influenza or Moraxella catarrhalis)
  • with a concurrent conjunctivitis (conjunctivitis-otitis syndrome) to cover for Haemophilus influenza

22.5mg/kg Amoxycillin component (up to maximum 500mg amoxicillin/125mg clavulanate per dose) 8-hourly for 5-7 days

Cephalexin (PO) If delayed type hypersensitivity (e.g. rash) to penicillins:

30 mg/kg/dose (maximum 1gram/dose) 8-hourly for 5 days

Trimethoprim+ sulfamethoxazole (PO) For children ≥ 1 month with immediate hypersensitivity to penicillins/cephalosprins:

4mg/kg/dose Trimethoprim component (up to 160mg Trimethoprim/800mg Sulfamethoxazole) 12-hourly for 5 days

Ciprofloxacin (Topical) (3mg/mL Ciloxan® eardrops) 5 drops BD

May shorten the duration of symptoms if a perforation or tympanostomy tube (grommet) is present with purulent otorrhoea18,19

Other treatments

The following treatments are not recommended as trials have demonstrated a failure to show any benefit: 14

  • antihistamines
  • decongestants

When to escalate care

Follow your local facility escalation protocols for children of concern. Transfer is recommended if the child requires care beyond the level of comfort of the treating hospital. Clinicians can contact the services outlined below to escalate the care of a paediatric patient.

Service Reason for contact by clinician Contact
Local Paediatric service For specialist paediatric advice and assistance with local transfers as per local arrangements. As per local arrangements
Children’s Advice and Transport Coordination Hub (CATCH) For access to specialist paediatric advice and assistance with inter-hospital transfer of non-critical patients into and out of Lady Cilento Children’s Hospital.

For assistance with decision making regarding safe and appropriate inter-hospital transfer of children in Queensland.

For QH staff, click here for further information including the QH Inter-hospital transfer request form (access via intranet).

(07) 3068 4510

CATCH website

24 hours

Telehealth Emergency Management Support Unit (TEMSU) For access to generalist and specialist acute support and advice via videoconferencing, as per locally agreed pathways, in regional, rural and remote areas in Queensland.

For QH staff, click here for further information (access via intranet).

TEMSU QHEPS website

24 hours

Retrieval Services Queensland (RSQ) For access to telehealth support for, and to notify of, critically unwell patients requiring retrieval in Queensland.

For any patients potentially requiring aeromedical retrieval or transfer in Queensland.

For QH staff, click here for further information and relevant forms (access via intranet).

RSQ QHEPS website

24 hours

Disposition

When to consider discharge

Most children with isolated AOM without systemic illness can be discharged home.

On discharge provide the parent with:

  • prescription for antibiotics (if needed)
  • advice regarding the management at home (including analgesia, taking care not to get water in ear if TM perforation) and criteria for medical review
  • Acute Otitis Media Factsheet

Follow-up

Recommended follow up with GP in 24-48 hours or up to 10 days depending on the management option chosen and the severity of the symptoms.

All children with a TM perforation should be reviewed by a GP to ensure the perforation has healed (usually around 10 days).

All children with AOM should be seen by their GP at 3 months to ensure the effusion has resolved.

Referral to ENT specialist may be considered for children who meet the following criteria:

  • effusion or perforation for > 6 weeks
  • hearing impairment for > 6 weeks
  • premature
  • Indigenous or Torres Strait Islander background

Aeroplane travel

Parents frequently present to the ED to have their child with AOM assessed before flying. Airlines recommend against flying if the passenger is unable to clear their eustachian tubes. This is difficult to assess in younger children. Recommendations for young children are based on expert opinion in the absence of evidence. Children should be safe to fly 2 weeks after an adequately treated AOM, however many clinicians recommend waiting only 48hrs. These children should be given a nasal decongestant at least 30 minutes prior to take-off and landing16 and analgesia prior to flying. During take-off and landing they can be encouraged to suck, chew or swallow or, if old enough, perform a Valsalva manoeuvre to help equalise pressure.

When to consider admission

Consider hospital admission for children with AOM who have:

  • failed outpatient treatment
  • serious complications
  • severe disease
  • significant co-morbidities

Related documents

References

  1. American Academy of Pediatrics — Subcommittee on Management of Acute Otitis Media. (2013), ‘Diagnosis and management of acute otitis media’, Pediatrics, Vol. 113 (5): 1451-1465.
  2. Rothman, R., Owens, T., Simel, D.L. (2003), ‘Does this child have acute otitis media?’, Journal of the American Medical Association, Vol. 290 (12): pp. 1633-16
  3. Ruuskanen, O., Heikkinen, T. Otitis media: etiology and diagnosis. Pediatric Infectious Diseases Journal, 1994;13 (1 suppl 1):S23-S26 (microbial)
  4. Marom, T. et al. Viral-Bacterial Interactions in Acute Otitis Media Current Allergy and Asthma Reports December 2012, 12 (6) 551-558
  5. Bluestone, C., Klein, J. Otitis Media in Infants and Children. 3rd ed. New York, NY: WB Saunders; 2001
  6. Ruohola, A.  Meurman,  O.  et  al.  Microbiology of  acute  otitis  media  in  children  with  tympanostomy tubes: prevalence of bacteria and viruses. Clin Infect Dis 2006;43:1417-22
  7. Brennan-Jones, CG., Whitehouse, AJ, et al. Prevalence and risk factors for parent-reported recurrent otitis media during early childhood in the Western Australia Pregnancy Cohort (Raine) Study. Journal Paediatrics and Child Health 2015 Apr 51(4) 403-9.
  8. Salah, , Abdel-Aziz, M et al. Recurrent acute otitis media in infants: analysis of risk factors. International Journal of Pediatric Otorhinolaryngology 2013; 77(10): 1665-9
  9. Liese, JG., Silfverdal, SA. Et al. Incidence and clinical presentation of acute otitis media in children aged <6 years in European medical practices. Epidemiology and Infection, 2014. 142.8: 1778-
  10. Berger, G. Nature of spontaneous tympanic membrane perforation in acute otitis media in children. J Laryngol Otol 1989; 103:1150-1153.
  11. Rosenfeld, R, and Kay, D. Natural history of untreated otitis media. Laryngoscope 2003; 113(10), 1645-57.
  12. UpToDate in Pediatrics. Holding a child to minimise movement during an exam. [internet].Available from: http://www.uptodatcom/contents/acute-otitis-media-in-children- diagnosis?source=search_result&search=otitis+media+children&selectedTitle=2%7E150
  13. Tintinalli, J.E.,  Stapczynski,  J.S.,  Ma,  O.J.,  Cline,  D.M.,  Cydulka,  R.K.,  Meckler,  G.D.,  (2011),  Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed McGraw-Hill]
  14. Leskinen, K. Complications of acute otitis media in children. Current Allergy and Asthma Reports, 2005; 5:308-
  15. Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.:CD000219.DOI: 10.1002/14651858.CD000219.pub4
  16. Canadian Paediatric Society. Air travel and children’s health issues. Paediatrics and Child Health, 2007. Jan; 12(1): 45-50

Guideline approval

Guideline approval history
Document ID CHQ-GDL-60000 Version no. 2.0 Approval date 19/6/19
Executive sponsor Executive Director Medical Services Effective date 19/6/19
Author/custodian Queensland Emergency Care Children Working Group Review date 19/6/22
Supersedes 1.0
Applicable to Queensland Health medical and nursing staff
Authorisation Executive Director Clinical Services QCH
Keywords Otitis, media, middle ear, infection, 00710, paediatric, children, emergency, guideline, 60000
Accreditation references NSQHS Standards (1-8): 1, 4, 8

Disclaimer

This guideline is intended as a guide and provided for information purposes only. View full disclaimer.
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