Acute Otitis Media
Red flags
Acute otitis media (AOM) in the presence of:
Sepsis with post auricular swelling
Cranial nerve palsy
Symptoms of meningism
Altered conscious state
Why is this important?
AOM can progress to extra- and intracranial complications
When to involve the ENT Registrar
Soon: If you’re concerned there may be a complication of AOM
Who to admit
Anyone with complications of AOM
Unwell young children with discharging ears (acute suppurative otitis media) if you are not sure whether there is a complication or not
Those with uncomplicated A(S)OM are not normally admitted
Assessment & recognition
AOM is one of the commonest infections in human beings and tends to affect children under the age of 7 years. Adults can also be affected but are more likely to have primary acute otitis externa.
AOM - A history of gradually increasing otalgia with no discharge. Red bulging drum on otoscopy. Common pathogens include Influenza virus, Haemophilus influenzae or Streptococcus pneumoniae.
Photo - Normal left tympanic membrane
Photo - Acute otitis media of the right ear; note the opaque and protruding drum with erythema and prominent blood vessels.
With thanks to Michael Hawke MD, Wikimedia Commmons
Acute suppurative otitis media (ASOM) - A history of gradually increasing otalgia followed by the appearance of a discharge with some reduction in otalgia. Patients sometimes hear/feel a 'pop' just before the discharge appears. On otoscopy, there is mucopurulent watery discharge in the ear canal and perforation of the tympanic membrane (TM). The TM may not be visible given the discharge and associated ear canal swelling (secondary otitis externa).
Associated features - Some hearing loss, tinnitus and fever. Small children may appear unwell, crying and be pulling at the affected ear.
Remember - Document facial nerve exam, neurological status and ear examination including mastoid area.
Immediate and overnight management
Discharge home with good analgesia and safety net advice for complications.
The use of oral antibiotics in A(S)OM is widespread and contrary to the available evidence.
You should follow NICE Guidelines and local antibiotic policy. Consider prescribing antibiotic and steroid combination drops for ASOM with or without secondary otitis externa. Drops and sprays such as ciprofloxacin, Sofradex and Otomize are frequently prescribed: follow your local antibiotic policy and/or seek specialist guidance.
In children, there is strong evidence that oral antibiotics reduce the number of days in pain slightly, but do not change the length of the illness or its outcome. The rates of complication in both antibiotic- and placebo-treated children were both very low and the same for both groups. A delayed prescription with safety-netting is appropriate in most situations.
NHS Evidence: Acute Otitis Media
Cochrane Review on Antibiotics for AOM in Children
Further management
No routine hospital follow-up is needed for uncomplicated AOM.
Page last reviewed: 8 January 2024