Acute Otitis Media

Also written as middle‑ear infection.

Acute otitis media (AOM) is a common middle‑ear infection in children, especially in low‑resource settings. Prompt recognition, appropriate antibiotics and monitoring prevent complications such as mastoiditis or hearing loss.

Overview

AOM is inflammation of the middle ear cavity, usually following viral upper‑respiratory infection that blocks the eustachian tube, allowing bacterial overgrowth.

• Otoscopic examination: Is there middle‑ear effusion and inflammation? Red bulging tympanic membrane, loss of landmarks, and reduced mobility confirm AOM.
• Pneumatic otoscopy (if available): Assesses tympanic membrane mobility; absent movement supports effusion.

• Typical age: 6 months–5 years
• Peak incidence after viral URI
• Higher risk with day‑care attendance, smoke exposure, and malnutrition

Key concepts

Diagnosis requires acute onset, middle‑ear effusion, and signs of inflammation. Severity is staged by the American Academy of Pediatrics (AAP) criteria: mild (pain only), moderate (pain + fever), severe (pain, fever + systemic signs).

• Full blood count (if available): Leukocytosis (>12 × 10⁹/L) suggests bacterial cause; normal count does not rule out AOM.

• Common pathogens: Streptococcus pneumoniae, Haemophilus influenzae (non‑typeable), Moraxella catarrhalis
• In HIV‑positive or malnourished children, consider Pseudomonas or Staphylococcus aureus
• Complications: mastoiditis, tympanic membrane perforation, hearing loss

Clinical relevance

In low‑resource hospitals, antibiotics may be limited; first‑line oral amoxicillin is preferred unless contraindicated. Monitoring for treatment failure (persistent pain >48 h, fever >72 h) is essential.

• Audiometry (if available): Assess hearing loss after repeated episodes; normal result reassures, abnormal prompts ENT referral.

• Give analgesia (paracetamol) for pain and fever
• Educate caregivers on ear‑drop safety and follow‑up
• If no improvement, consider second‑line (e.g., cefuroxime) or referral for drainage

Exam pearls

Exam questions often test differentiation of AOM from otitis externa, mastoiditis, and serous otitis media, as well as appropriate antibiotic choice and recognition of red‑flag complications.

• AOM: bulging, erythematous TM; otitis externa: painful external canal, no TM bulge
• Mastoiditis: post‑auricular swelling, tenderness, fever, possible displacement of ear
• Serous otitis media: dull TM, no pain, often after URI

Common mistakes

Students frequently over‑investigate with tympanometry or CT scans, or prescribe broad‑spectrum antibiotics unnecessarily.

• Relying on tympanometry when pneumatic otoscopy is sufficient
• Using macrolides first line despite high resistance in the region
• Missing mastoiditis signs and delaying referral

Questions an examiner may ask

• A 2‑year‑old presents with ear pain, fever 38.5 °C, and a bulging tympanic membrane – what is your next step? — Start oral amoxicillin, give analgesia, arrange review in 48 h.
• How does otitis media differ from otitis externa on examination? — AOM shows bulging TM, otitis externa shows painful external canal with normal TM.
• A child with HIV on ART develops AOM; which organism should you consider and how does it affect antibiotic choice? — Consider Pseudomonas; may need broader‑spectrum agent like cefuroxime.
• What are the red‑flag signs that mandate referral to ENT? — Post‑auricular swelling, persistent high fever, neurological symptoms, or no improvement after 48 h of appropriate antibiotics.
• Why is macrolide monotherapy discouraged in this setting? — High local resistance of Streptococcus pneumoniae reduces efficacy and promotes resistance.
• Explain the AAP severity staging for AOM and its impact on management. — Mild (pain only) may be observed; moderate (pain + fever) needs antibiotics; severe (pain, fever, systemic signs) requires prompt antibiotics and close follow‑up.
• A patient cannot tolerate oral medication; what is the alternative route and drug? — Use intramuscular benzylpenicillin or ceftriaxone, chosen for coverage and once‑daily dosing.
• What complication can cause permanent hearing loss if untreated, and how is it prevented? — Chronic suppurative otitis media; early effective antibiotics and ear‑drainage prevent progression.

When to seek help

• Severe ear pain with swelling behind the ear (mastoiditis)
• Persistent fever >39 °C for >72 h despite antibiotics
• Neurological signs (headache, vomiting, altered consciousness)

Quick questions

Why is amoxicillin preferred as first‑line therapy?

It covers the most common pathogens, is inexpensive, and has low resistance rates in most East African settings.

When should I suspect mastoiditis?

Post‑auricular erythema, tenderness, swelling, or protrusion of the ear, especially with persistent fever.

Can AOM resolve without antibiotics?

Mild cases may improve with analgesia alone, but guidelines recommend antibiotics for children under 2 years or severe disease.