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Acute Otitis Media (AOM)

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 High risk populations (Aboriginal and/or Torres Strait Islander populations). In some
rural and remote Aboriginal communities complications of Otitis media are much more
common. They include hearing loss, tympanic membrane perforations, CSOM, OME and
mastoiditis. This is the reason that a different antibiotic regime is recommended in these
children. In low risk populations (non-Aboriginal and/or Torres Strait Islander populations) the
advantage of antibiotics is small unless systemic features are present.
 Infection behind the eardrum may cause the drum to rupture
 AOM with perforation occurs mainly in the first 18 months of life and effective treatment will
dramatically reduce the incidence of chronic suppurative Otitis media (CSOM)
 Ciprofloxacin drops are restricted on the Pharmaceutical Benefits Scheme (PBS) to the
treatment of chronic suppurative Otitis media:
– in an Aboriginal and/or a Torres Strait Islander patient aged ≥ 1 month
– in a patient < 18 years of age with perforation of the tympanic membrane
– in a patient < 18 years of age with a grommet insitu

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Diagnosis

Diagnosis of AOM may be difficult as there are no definitive symptoms and no ‘gold standard’ for
diagnosis. Signs can cover a spectrum as the disease progresses. An erythematous tympanic
membrane together with otalgia have been regarded as indicating AOM, but only 40% of children with
these features actually have AOM. In addition, otoscopy is recognised as one of the most technically
difficult tasks to perform in young children.

A recent systematic review recommended three main criteria that need to be met for a diagnosis of
AOM:

• acute symptoms of infection

• evidence of middle ear inflammation, such as tympanic membrane erythema.
• presence of middle ear effusion.

Otoscopy

Similarly, diagnosing AOM based on otoscopic signs can be difficult in children.

Otoscopy requires patience, a compliant child and a parent confident enough to adequately restrain
their child if required. Furthermore, in nearly 80% of children under the age of 12 months, the tympanic
membranes are either partially or totally obscured by wax, hindering accurate diagnosis.

Otoscopy can be more fruitful if the child is positioned on the parent’s lap, with one of the parent’s
arms restraining the child’s shoulder and the other arm holding the child’s head against the parent’s
chest. If wax is present, it can be removed in a compliant child with a wax curette or with the help of
topical preparations.

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Symptomatic treatment with adequate and regular analgesia is very important.
 As an adjunct, short-term use of topical 2% lignocaine, 1-2 drops applied to an INTACT
tympanic membrane may be effective for severe acute ear pain.
 Decongestants, antihistamines and corticosteroids are not effective in AOM.
Most cases of AOM in children resolve spontaneously. The routine use of antibiotic treatment should
be avoided.
 Infants <6 months old, including neonates: AOM is difficult to ascertain, and other diagnoses
should be fully considered.
 Infants 3-6 months of age: clear diagnosis of AOM and systemically well - manage as per
flowchart below.

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Follow up:

 Review the patient in 4 - 7 days or earlier if indicated

 If red or bulging eardrum persists after seven days increase dose of amoxycillin to 90
mg/kg/day
 Review at next MO/NP visit. For weekly review until the signs of AOM and/or perforation have
resolved.
 Review after completion of treatment at the 1 week mark
 If failing to resolve discuss with parents/carer - explore if the child is being given antibiotics. Is
the child spitting it out or vomiting afterwards?
 If discharge continues after 2 weeks of treatment check with family on ability to clean the ear
and instil drops.
 If perforation heals review in 6 weeks:
–– inspect eardrum with an otoscope
––perform hearing assessment - tympanometry from 6 months of age, and then audiometry
from around 3 years of age
Ask family about child's hearing, speech development, behaviour, school progress. If there are
concerns about any of these refer for formal hearing assessment if not done recently
 To prevent recurrent OM and transmission of bacteria to other children encourage personal
hygiene in children - regular nose blowing and washing of hands and face.
 Review at 3 months to identify those with chronic disease

Consult MO/NP as above

 If otitis media is recurrent the MO/NP may consider antibiotics for prophylaxis1
 Where prolonged medical therapy fails i.e. > 6 weeks, or frequent painful AOM, the MO/NP
may refer to ENT Specialist
 Any patient with an attic perforation requires urgent referral to ENT Specialist
 Refer for audiology if concerns about hearing, speech, language development, learning
difficulties or the child has had recurrent AOM
 If hearing is impaired in school children make sure the school is informed, with parental
consent, as teacher can use measures to assist child e.g. sound field amplification systems
and student placement.

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