B-QuiCK: Otitis media

B-QuiCK: Otitis media

Acute otitis media (AOM)

Assessment and diagnosis

• Assess/ask about symptoms and signs consistent with an ear infection, e.g. otalgia and fever; in younger children, i.e. aged two years and under, symptoms may be non-specific, e.g. ear tugging, irritability and not settling at night
• Use an otoscope to check for inflammation and effusion; the tympanic membrane may:
  • Show areas of intense erythema or yellow colouration
  • Lack translucency and be dull or cloudy
  • Bulge and show a loss of normal landmarks

Management

• Most cases spontaneously resolve without the need for antibiotics
• Recommend symptom relief with regular analgesics, e.g. paracetamol or ibuprofen, if required, and watchful waiting for 24 – 48 hours
• Consider prescribing antibiotics in children:
  • Aged under six months
  • Aged two years and under with bilateral or severe infection, e.g. moderate-to-severe otalgia and/or fever > 39°C
  • Whose condition worsens, or does not improve within 48 hours
  • Experiencing recurrent episodes of otitis media, i.e. ≥ 3 episodes within six months, or ≥ 4 episodes within 12 months
  • At high risk for developing complications, e.g. children:
    • Who are immunocompromised
    • With infection in their only hearing ear or in children with a cochlear implant
    • Who are systemically unwell or there is evidence of sepsis
    • Who have a possible suppurative complication
• A “back pocket” prescription may be appropriate
• Check with local HealthPathways for specific ENT referral criteria

Otitis media with effusion (OME)

Assessment and diagnosis

• Ask about hearing loss or any non-specific symptoms, e.g. difficulties with communication, lack of attention, sleep and balance disturbances, irritability
• Use an otoscope to examine for dullness and tympanic membrane retraction
• Use tympanometry – a type B curve trace suggests OME

Management

• Recommend watchful waiting for three months, with regular follow-up during this period, e.g. return after four weeks to check resolution and monitor for any hearing changes; antibiotics are not necessary
• Refer to ENT for consideration of grommet insertion if effusion persists for longer than three months. Also consider referral to audiology or a child speech language therapist if there is suspicion of speech and language delay in children aged > 2.5 years. Check local HealthPathways for specific referral criteria.

Chronic suppurative otitis media (CSOM)

Assessment and diagnosis

• Ask about the duration of otorrhoea (persisting for at least two to six weeks) and any suspicion of hearing loss
• Assess the ear for otorrhoea and examine the tympanic membrane, if visible, for perforation and erythema

Management

• Treatment usually begins with topical ear drops containing a combination of anti-infective and anti-inflammatory agents
  • Ciproxin HC (not funded) is often recommended first-line on the balance of benefit and safety; consider the possibility of resistance
  • Sofradex (partly funded), Kenacomb (funded) and Locorten-Vioform (funded) may be appropriate alternatives
• If combination drops are unsuccessful at resolving otorrhoea, consider swabs to direct further treatment or discuss with an ENT specialist or request a paediatric ear nurse (if available) or ENT assessment