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. There is a spectrum of disease ranging from AOM through severe AOM to mastoiditis and subperiosteal abscess. Given the number of patients who contract middle ear infections, mastoiditis is relatively rare. Key diagnostic criteria are in bold:

  • Tenderness of the mastoid can be normal with uncomplicated ear infections such as otitis externa: mastoiditis patients are systemically very unwell.

  • Patients with mastoiditis are septic: pyrexial, anorexic and lethargic. Children will be irritable and will not feed.

  • Patients will have signs and symptoms of an underlying ear infection eg red, bulging tympanic membrane or purulent ear discharge.

  • The sharp angle between the ear and the mastoid, the auriculomastoid sulcus, is lost: compare with the contralateral ear.

  • As the disease progresses, the pinna is classically pushed downwards and forwards with boggy oedema of the mastoid: compare with the contralateral ear.

  • Mastoiditis can spread from deep to superficial, forming an abscess beneath the periosteum of the mastoid bone: the swelling typically becomes fluctuant at this stage.

  • Rarely, such 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, retro-orbital or eye pain (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. 

Investigations

• Microbiological swabs of any discharge and blood cultures before IV antibiotics

• FBC, U&E, CRP, G&S

• CT head/temporal bones may be required – discuss with the ENT Registrar (many patients undergo a 24 hour trial of IV antibiotics first)

• LP if there are signs of meningitis – discuss this with the Medical or Paediatric Registrar

Treatment

• Close neurological observation for meningitis and other 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 who worsen in the first 24 hours

Further management

• Facial palsy – myringotomy +/- grommet insertion

• Mastoiditis – cortical mastoidectomy, possible incision and drainage of spreading abscesses

• Bacterial labyrinthitis – observe carefully for signs of meningitis

• Meningitis – may need mastoid exploration at a later date

• Sigmoid sinus thrombosis – neurosurgical management eg anticoagulants or surgery

• Brain abscess – neurosurgical management

Page last reviewed: 15 December 2019