Ear, Nose & Throat
A 34 year old woman with a history of insulin dependant diabetes presents to the Emergency Department with a 2 day history of left "earache". On examination you note normal observations except for a mild fever. On inspection you see a bulging tympanic membrane in the left ear. The right ear is normal. Which of the following is the most appropriate management strategy?
Answer:
Offer an immediate antibiotic prescription for people who do not require admission to hospital but are systemically very unwell, have symptoms and signs of a more serious illness or condition, or have a high risk of complications.Acute Otitis Media
Ear, Nose & Throat
Last Updated: 12th February 2021
Acute otitis media (AOM) is defined as the presence of inflammation in the middle ear, associated with effusion and accompanied by the rapid onset of symptoms and signs of an ear infection. This is to be differentiated from otitis media with effusion (OME), which is characterised by fluid in the middle ear, but is not associated with symptoms and signs of an acute ear infection.
Causes
AOM may be caused by viral or bacterial infection. The most common bacterial pathogens are Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Streptococcus pyogenes. Viral pathogens associated with AOM include respiratory syncytial virus (RSV), rhinovirus, adenovirus, influenza virus, and parainfluenza virus.
AOM occurs frequently in children but is less common in adults. Children are more likely to develop AOM because they acquire viral infections more often than adults, and have shorter and more horizontal eustachian tubes.
Complications
Potential complications of AOM include:
- Persistent otitis media with effusion
- Recurrence of infection
- Hearing loss (conductive and usually temporary)
- Tympanic membrane perforation
- Labyrinthitis
- Rarely, mastoiditis, meningitis, intracranial abscess, sinus thrombosis and facial nerve palsy
Diagnosis
- Diagnose acute otitis media (AOM) if there is:
- Acute onset of symptoms, including:
- In older children and adults — earache.
- In younger children — holding, tugging, or rubbing of the ear, or non-specific symptoms such as fever, crying, poor feeding, restlessness, behavioural changes, cough, or rhinorrhoea. Note that these non-specific symptoms do not help differentiate AOM from upper respiratory tract infection.
- On otoscopic examination:
- A distinctly red, yellow, or cloudy tympanic membrane.
- Moderate to severe bulging of the tympanic membrane, with loss of normal landmarks and an air-fluid level behind the tympanic membrane (indicates a middle ear effusion).
- Perforation of the tympanic membrane and/or discharge in the external auditory canal.
- Acute onset of symptoms, including:
- Consider whether findings may be explained by other causes of middle ear inflammation or effusion.
- Note that clinical features not suggestive of AOM include a tympanic membrane which is not bulging (with or without erythema or cloudiness), and an air-fluid level without a bulging tympanic membrane.
- In children younger than 6 months of age (and particularly younger than 3 months of age), diagnosis can be difficult because:
- There may be coexisting systemic illness, such as bronchiolitis or bacteraemia.
- Symptoms are likely to be non-specific.
- The tympanic membrane may not be visible; it often lies in an oblique position and the ear canal is small and tends to collapse.
Management
- Admission:
- Admit for immediate specialist assessment:
- People with a severe systemic infection.
- People with suspected acute complications of acute otitis media (AOM), such as meningitis, mastoiditis, intracranial abscess, sinus thrombosis, or facial nerve paralysis.
- Children younger than 3 months of age with a temperature of 38°C or more.
- Consider admitting:
- Children younger than 3 months of age.
- Children 3–6 months of age with a temperature of 39°C or more.
- Admit for immediate specialist assessment:
- Antibiotic prescription:
- Offer an immediate antibiotic prescription for people who do not require admission to hospital but are systemically very unwell, have symptoms and signs of a more serious illness or condition, or have a high risk of complications.
- For people without the above features, consider:
- No antibiotic prescription with advice about an antibiotic not being needed and seeking medical help if symptoms worsen rapidly or significantly, do not improve after 3 days, or the person becomes systemically very unwell.
- A back-up antibiotic prescription with advice about an antibiotic not being needed immediately; using the back-up prescription if symptoms do not start to improve within 3 days or worsen significantly or rapidly at any time; and seeking medical help if symptoms worsen rapidly or significantly, or the person becomes systemically very unwell.
- An immediate antibiotic prescription for people who may be more likely to benefit from antibiotics e.g. those with otorrhoea or those aged < 2 years with bilateral infection.
- If an antibiotic is required:
- Prescribe a 5–7 day course of amoxicillin.
- For people who are allergic to, or intolerant of, penicillin, prescribe a 5–7 day course of clarithromycin or erythromycin.
- Patient advice:
- Advise that the usual course of acute otitis media is about 3 days, but can be up to 1 week.
- Advise regular doses of paracetamol or ibuprofen for pain, using a dosing schedule appropriate for the age and weight of a child.
- Explain that there is no evidence to support the use of decongestants or antihistamines for the management of symptoms.
- Advise them to seek medical advice if symptoms worsen rapidly or significantly or they become systemically very unwell.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
