Acute Otitis Media

Question 1

Which region of the ear does otitis media affect?

Answer 1

Middle

Question 2

What is otitis media?

Answer 2

Inflammation of the middle ear associated with effusion and a rapid onset of symptoms, with signs of infection

Question 3

Aetiology(Cause)

Answer 3

Acute otitis media often occurs after an upper respiratory tract infection (URTI) e.g. a ‘cold’
This infection can lead to swelling of the lining of the nose, throat and Eustachian tube. The swelling of the Eustachian tube blocks the drainage of fluid from the middle ear, fluid builds up and creates pressure behind the ear drum. The congested fluid can become infected with viruses or bacteria or frequently, both.

Question 4

Presenting symptoms

Answer 4

Earache, partial loss of hearing (the fluid reduces the vibrations of the tympanic membrane and ossicles); possible fever, malaise and discharge, which may contain pus
Young children may hold, rub or tug at their ear; they may also present with non-specific symptoms such as crying, poor feeding, restlessness or a cough

Question 5

Otoscopic inspection

Answer 5

Reveals a red, yellow or cloudy tympanic membrane which may be bulging. An air-fluid level of the effusion may be visible.
The tympanic membrane may be perforated with or without discharge.

Question 6

Prevalence

Answer 6

Otitis media occurs most frequently in children, but can occur in adults
It is most common in babies and children up to the age of 4 years *

Question 7

Causal Risk Factors

Answer 7

Exposure to smoking
Children who attend nursery or day-care or have siblings (exposure to viruses)
Formula-fed babies/infants (breastfeeding has a protective effect)
Prolonged feeding in the supine position
Use of a dummy
Male sex
Craniofacial abnormalities (e.g. a cleft palate)

Question 8

Use of antibiotics

Answer 8

Antibiotics make little difference to the resolution of the condition and are not required in the vast majority of patients.

However, antibiotics should be considered for patients who (as examples):
Have a discharge from the ear (otorrhoea) due to a perforated ear drum
Are younger than 2 years old and have bilateral infection (both ears)
Are systemically very unwell (but do not require hospital admission) or at risk of complications

Applicable antibiotics, where safe and appropriate, are:
Amoxicillin for 5-7 days (amoxicillin is a type of penicillin)
In penicillin allergy/intolerance: clarithromycin or erythromycin

Question 9

Management

Answer 9

‘Watchful waiting’ and an analgesic, if appropriate and required

In children and young people under18 years old, not prescribed oral antibiotics and with no otorrhoea or ear drum perforation, ear drops containing an analgesic and anaesthetic (medication which causes numbness) can be prescribed, if appropriate

A ‘back-up’ prescription for antibiotics may be supplied with advice not to have the antibiotic dispensed unless
symptoms worsen suddenly or significantly
or do not improve after three days
or the patient becomes systemically unwell

Question 10

Safety Netting

Answer 10

The patient should return or seek medical advice if
symptoms worsen suddenly or significantly
or symptoms do not improve or resolve within the expected timeframe
or the patient becomes systemically unwell

Question 11

Red Flag Management

Answer 11

In some cases, pharmacists may have the appropriate training, experience and clinical environment to manage patients with ‘red flag’ symptoms.

However, if this is not the case, referral for medical or specialist attention should be considered for patients who (e.g.)

Have a systemic infection
Have suspected complications (e.g. meningitis, severe pain behind the ear, facial nerve paralysis*)
Are younger than three months with a temperature of 38 ºC or higher