Complications of 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?

The complications of AOM are potentially life-threatening 

When to involve the ENT Registrar

When you suspect a complication of AOM, assess (and, if required, resuscitate) the patient and discuss promptly with the ENT Registrar. You will probably need to discuss imaging needs eg CT head with the Radiology Registrar. You may need to involve the Medical or Paediatric Registrar if a lumbar puncture (LP) is needed and a neurosurgeon if indicated by the results of the LP and imaging.


Who to admit

Admit anyone you suspect of having mastoiditis, petrositis or any intracranial complication of AOM.


Assessment & recognition

Take a thorough history and perform a full ENT and neurological exam including cranial nerves and bedside hearing tests. All these patients will have signs and symptoms of AOM. The complications of AOM may have become rarer with the advent of antibiotics. A Cochrane review, however, found that antibiotic- and placebo-treated children had similar and very low rates of complications.  

Extracranial complications

  • Facial Palsy – AOM and a facial palsy without sparing of frontalis. Record the grade of palsy on the House-Brackmann scale, especially commenting on eye closure. This is usually due to a dehiscent facial nerve canal in the middle ear allowing the infection to affect the nerve itself. Patients usually recover well when the infection has resolved.
  • Mastoiditis – Infection spreading from the middle ear to form an abscess in the mastoid air spaces of the temporal bone.
    • Note that tenderness of the mastoid can be normal with uncomplicated ear infections such a otitis externa: mastoiditis implies that a patient is systemically very unwell. 
    • Given the number of patients who contract middle ear infections, mastoiditis is relatively rare.
    • Patients with mastoiditis are septic: pyrexial, anorexic and lethargic. Children will be irritable and will not feed. Patients will have signs and symptoms from the underlying ear infection. There will be a significant erythematous and tender swelling behind the ear that typically pushes the pinna down and forwards. 
    • Mastoiditis can spread superficially from deep inside the air cells to form a subperiosteal abscess: the mastoid swelling can become noticeably fluctuant in some cases.
    • Rarely, mastoid abscesses can spread inferiorly to the sternomastoid sheath (Bezold's abscess), into the digastric muscle (Citelli's abscess), as well as superomedially to the petrous apex of the temporal bone (petrositis).
  • Petrositis – Infection spreading to the apex of the petrous temporal bone. There will be sepsis and signs and symptoms of mastoiditis. There is a triad of symptoms known as Gradenigo's Syndrome which entails: purulent otorrhoea, pain deep inside the ear and eye (cranial nerve V1 distribution) and ipsilateral lateral rectus palsy (cranial nerve VI).

Intracranial complications

  • Meningitis – Sepsis, headache, vomiting, neck rigidity, photophobia and positive Kernig’s sign (pain on meningeal stretch eg chin to chest or straight leg raise).
  • Sigmoid sinus thrombosis – Sepsis, swinging pyrexia and meningitis. If there is distal propagation of the clot then there is a palpable cord in the neck. If there is propagation of the clot to the cavernous sinus, then signs can include proptosis, ophthalmoplegia and chemosis. These patients frequently have another intracranial complication.
  • Brain abscess – Sepsis with neurological signs. Collections can occur extradurally, subdurally or intracerebrally. Prompt involvement of the neurosurgical team is important.


Immediate and overnight management

This depends on the presentation but the following would be appropriate in most cases.

Bear in mind the Sepsis Resuscitation Bundle when managing septic patients. 



  • Microbiological swabs of any discharge and blood cultures before IV antibiotics
  • FBC, U&E, CRP, G&S
  • CT head/temporal bones may be required – timing of this depends on the presentation so discuss with the ENT and Radiology Registrars
  • LP if there are signs of meningitis – discuss this with the Medical or Paediatric Registrar



  • Close neurological observation for meningitis and other signs eg eye signs 
  • 24 hour trial of broad spectrum IV antibiotics, according to local policy 
  • Combination antibiotic and steroid ear drops
  • Good analgesia
  • IV fluids if the patient is vomiting or dehydrated
  • Artificial tears and eye lubrication if there is facial palsy
  • Short term vestibular sedative eg prochlorperazine if there is dizziness/vertigo 
  • Keep nil by mouth if you are concerned the patient may need operative management: usually, operative management is reserved for patients who do not improve or worsen in the first 24 hours


Further management

  • Facial palsy – myringotomy +/- grommet insertion
  • Mastoiditis – cortical mastoidectomy, possible incision and drainage of spreading abscesses
  • Labyrinthitis – observe carefully for signs of meningitis
  • Meningitis – may need mastoidectomy at a later date
  • Sigmoid sinus thrombosis – neurosurgery to remove the infected clot, possibly anticoagulants
  • Brain abscess – neurosurgical management


Page last reviewed: 20 January 2018