What is Otitis Media (middle ear infection) ?

by

Dr Zaid Ismail

Otitis media is a common childhood condition, with most cases occurring in those under 5 years. It encompasses acute otitis media (AOM), otitis media with effusion (OME), and chronic suppurative otitis media (CSOM). AOM is the most frequently encountered in primary care.

Clinical features

  • Ear pain (otalgia)
  • Fever
  • Irritability or sleep disturbance (in children)
  • Hearing loss
  • Tympanic membrane findings: bulging, erythema, reduced mobility

In OME, symptoms are often milder and typically include hearing loss or a sensation of fullness without acute pain or fever.

Diagnosis

AOM is diagnosed clinically. Pneumatic otoscopy may aid in confirming middle ear effusion. Distinguish from otitis externa (involves the outer ear canal, pain on tragus movement).

Red flags:

  • Mastoid tenderness or swelling (mastoiditis)
  • Cranial nerve palsies
  • Recurrent episodes (>3 in 6 months or >4 in 12 months)
  • Symptoms persisting >72 hours despite treatment

Management

Acute Otitis Media

  • Most cases are self-limiting.
  • NICE guidance (NG91) recommends:
    • No antibiotics for mild cases in children >2 years
    • Back-up antibiotic prescription or immediate antibiotics if:
      • Systemically unwell
      • Symptoms for >4 days
      • Bilateral AOM in children <2 years
      • Otorrhoea
  • First-line: Amoxicillin 5 days
  • Penicillin allergy: Clarithromycin or Erythromycin
visual-summary-pdf-4787282702Download

Otitis Media with Effusion

  • Watchful waiting for up to 3 months.
  • Refer for audiology if persistent effusion with hearing loss >25–30 dB.
  • Grommets may be considered per NICE NG36 if significant impact on hearing, speech, or development.

Referral criteria

  • Suspected complications (mastoiditis, intracranial spread)
  • Hearing loss impacting development
  • Recurrent AOM despite adequate management
  • Persistent otorrhoea (>6 weeks)

Follow-up

  • Not routinely required for uncomplicated AOM
  • OME: Reassess hearing at 3 months
  • Safety-netting: Advise parents to return if symptoms worsen or do not improve in 3 days

Summary

Otitis media is common and usually self-limiting. Judicious antibiotic use is key. Recognise red flags and know when to refer, particularly in persistent or complicated cases.

References:

Categories