Acute Otitis Media

Acute Otitis Media (AOM) is common in children under 5 years of age and is often a self-limited illness lasting several days. The mainstay of AOM management is symptom/pain control. In some cases, AOM can be more prolonged or severe and requires antibiotic treatment.

• Most common over 6 months of age but can occur in infants 3-6 months.
• Symptoms are acute in onset. These include ear pain and non-specific symptoms such as fever, crying, irritability, and/or sleep disturbance.
• Otoscopic criteria for AOM are:
  • Presence of a middle ear effusion AND inflammation (bulging, red or yellow tympanic membrane with loss of bony landmarks or presence of an air-fluid level).
    -OR-
  • Acute perforation of TM (may see perforation or pus in the external canal).

• Distinguish AOM from:
  • Chronic Suppurative Otitis Media: painless otorrhoea from a previously ruptured TM or myringotomy tube without acute or systemic symptoms
  • Otitis externa: otorrhoea with pain on movement of the pinna/tragus, without systemic symptoms
  • Chronic effusion: TM usually retracted, dull or amber-coloured and no new ear pain
• Tympanic membrane (TM) erythema can be seen with fever or a viral illness but the TM will not be bulging.
• CAUTION: Patients with cochlear implants who are diagnosed with AOM should be discussed with an ENT specialist. Patients who are immunocompromised should be followed carefully for appropriate clinical resolution.

MILD OR MODERATE SYMPTOMS

• AOM associated with mild symptoms will often resolve spontaneously (80%) over 24-72 hours and should not be treated routinely with antibiotics (since these are likely viral).
• Use oral ibuprofen and/or acetaminophen as needed. Refer to TREKK Recommendations for Pain Treatment for dosing. Counsel that the need for analgesia/antipyretics should decrease over the subsequent 24-48 hours if improving.
• Observe without antibiotics for 24-48 hours if:
  • Mildly ill (e.g., alert, responsive, pain and/or fever responding well to analgesia/antipyretics)
    -AND-
  • Symptomatic for less than 48 hours
    -AND-
  • 6 months of age or older
• Assure access to follow-up with a healthcare provider if symptoms persist, worsen, or child becomes systemically unwell.
• Alternatively, a back-up antibiotic prescription can be given with instructions to start treatment if pain does not improve in 24-48 hours but child remains systemically well.

SEVERE SYMPTOMS

• Provide antibiotic prescription at diagnosis if ANY of the following:
  • Young infant 3 to <6 months of age
  • Significant symptoms (high fever, difficulty sleeping, severe pain, poor feeding) despite regular analgesia/antipyretics
  • Symptomatic for greater than 48 hours
  • Acutely perforated TM
  • Bilateral AOM in children under the age of 2 years

• Shared decision-making with caregiver should include discussion of severity of illness, risks of antibiotics, and access to medical follow-up.
• Manage the child’s pain while treatment with antibiotics is underway using oral ibuprofen and/or acetaminophen. Most children will not need analgesia after 48 hours of effective treatment.
• Treat initially with Amoxicillin as most cases of AOM are due to S. pneumoniae.

• Acute mastoiditis presents with pain and/or swelling over the mastoid bone, often with outward deviation of pinna. Petrous bone inflammation presents with unilateral facial palsy (CN VII) and/or diplopia on lateral gaze (CN VI).
• Venous sinus thrombosis or meningitis presents with lethargy, irritability, persistent or severe headache and/or cranial nerve palsies.

These conditions require additional investigations (e.g., advanced imaging and lumbar puncture), IV antibiotics, subspecialty consultation (e.g., ENT), admission and if required, Pediatric Referral Site consultation/transfer.

Suggested citation: Le Saux, N. & Translating Emergency Knowledge for Kids (TREKK). (2022). Bottom Line Recommendations: Acute Otitis Media. Retrieved from https://trekk.ca/topic/aom.

Thank you to the following content expert who led the development of the Acute Otitis Media Bottom Line Recommendations:

Dr. Nicole Le Saux, MD 

Clinical Investigator, CHEO Research Institute, Division of Infectious Diseases, Children’s Hospital of Eastern Ontario (CHEO)
Professor, Department of Pediatrics, University of Ottawa

Thank you to the TREKK Editorial Committee, editor Dr. Sarah Reid (CHEO), who provided editorial support and expertise in the development of this resource. Thank you as well to TREKK Research Coordinator Mateja Carevic (University of Manitoba), who coordinated the review and update process.

This summary is based on:

1. Le Saux N, Robinson JL. Management of acute otitis media in children six months of age and older. Paediatr Child Health 2016; 21:39-50.
2. Liberthal A et al. & American Academy of Pediatrics. The diagnosis and management of acute otitis media. Pediatrics 2013;131 (3).
3. Hoberman A, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med 2011; 364:105-15.
4. Shaikh N, Hoberman A, Kaleida P, Ploof D, Paradise J. Diagnosing Otitis Media – Otoscopy and Cerumen Removal (Video). N Engl J Med 2010; 362:e62.
5. Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2015;2015(6):CD000219. Published 2015 Jun 23.
6. National Institute for Health and Care Excellence. Otitis media (acute): antimicrobial prescribing. Published March 28, 2018. Accessed August 30, 2022.

 

To see our resource development process please visit our website here.

For a complete list of the evidence that informed the creation of the Acute Otitis Media Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of acute otitis media in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use