AKT · ENT/Ear & hearing

Acute otitis media

Middle-ear infection (Strep pneumoniae, H. influenzae, Moraxella)

Overview

Acute infection of the middle ear, very common in young children (short, horizontal Eustachian tube), usually following a URTI. Ear pain and fever with a red, bulging tympanic membrane; most resolve spontaneously, so antibiotics are used selectively.

Recognise

Otalgia (young children: ear-tugging, irritability, fever) after a URTI
Otoscopy: red, BULGING tympanic membrane with loss of the light reflex; may perforate → purulent discharge + pain relief
Conductive hearing loss during the episode

Red flags

Mastoiditis (post-auricular swelling/erythema pushing the pinna forward), intracranial spread, or a child who is systemically very unwell

Differentials & how to tell them apart

Otitis externatragal/pinna tenderness with a debris-filled canal and a normal middle ear

Otitis media with effusion (glue ear)painless hearing loss with a dull retracted drum and effusion, NO acute inflammation

Mastoiditispost-auricular swelling/tenderness pushing the pinna forward — a complication needing admission

Referred pain (dental, tonsillar)normal ear examination

Acute otitis media — red, bulging eardrum
B. Welleschik / CC BY-SA 3.0 — Wikimedia Commons

Investigations

Clinical (otoscopy). No routine investigation. Recurrent/persistent effusion → audiometry/tympanometry later.

Management

Analgesia + safety-net; amoxicillin only if indicated (or a delayed prescription)

1Most resolve in ~3 days with analgesia and safety-netting. Offer an antibiotic (amoxicillin 5 days) or a back-up prescription rather than treating everyone.Gate: Reserve IMMEDIATE antibiotics for: systemically unwell, <2 years with BILATERAL AOM, otorrhoea (perforation/discharge), or high-risk comorbidity — otherwise analgesia ± a delayed prescription; over-treating AOM is the common error
2Penicillin allergy → clarithromycin/erythromycin. Complications (mastoiditis, facial palsy, intracranial) → urgent ENT/admission.

Analgesia (paracetamol/ibuprofen) — the mainstay — most cases are self-limiting

Amoxicillin (5 days) — first-line antibiotic when indicated; clarithromycin/erythromycin if penicillin-allergic

Delayed/back-up prescription — an option — use only if not improving in 3 days

Key points

Bulging red drum = AOM. Most are viral/self-limiting — antibiotics change the course little. The immediate-antibiotic criteria (unwell, <2y bilateral, discharge) are high-yield.

Monitor & prognosis

Resolution in days; persistent effusion (glue ear) over weeks; recurrence.

Excellent; perforations usually heal.

Source: NICE NG91 (otitis media - acute); NICE CKS