Otitis Media

Acute Otitis Media (AOM) is characterized by the presence of inflammation in the middle ear accompanied by the rapid onset of symptoms and signs such as otalgia, fever, and a red, bulging tympanic membrane. It is extremely common in the paediatric population, with a peak incidence between 6 and 15 months of age. The condition often follows a viral upper respiratory tract infection (URTI) which leads to eustachian tube dysfunction. Complications, though rare in the antibiotic era, include mastoiditis, meningitis, and facial nerve palsy. A related condition, Otitis Media with Effusion (OME), is characterized by fluid in the middle ear without acute inflammatory signs and is the most common cause of conductive hearing loss in school-aged children. Chronic Suppurative Otitis Media (CSOM) involves a persistent perforation of the tympanic membrane with chronic ear discharge (otorrhoea). NICE guidance (NG91) emphasizes that AOM is usually self-limiting, typically lasting around 3 days. Prescribing should be targeted at those who are systemically unwell, have comorbidities, or are at high risk of complications. For OME, a 'watch and wait' approach for 3 months is standard before considering surgical intervention like grommet insertion.

The pathophysiology of Otitis Media centers on Eustachian Tube (ET) dysfunction. In children, the ET is shorter, more horizontal, and narrower, facilitating the migration of pathogens from the nasopharynx to the middle ear. Viral URTIs (e.g., RSV, Rhinovirus) cause mucosal oedema and inflammation, which leads to ET obstruction. This creates negative pressure in the middle ear, promoting the accumulation of secretions and providing a medium for bacterial growth. Common bacterial pathogens isolated include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. In OME, chronic inflammation leads to the transformation of the middle ear lining into secretory epithelium with increased goblet cell density, producing thick, tenacious fluid (glue ear). This fluid dampens the vibration of the ossicular chain, leading to a conductive hearing loss. Resolution occurs when ET function is restored, allowing middle ear aeration and drainage. Genetic factors, craniofacial abnormalities (e.g., Cleft Palate), and environmental factors like tobacco smoke exposure also play significant roles in pathogenesis by impairing ciliary function and promoting bacterial biofilm formation.

Patients with AOM typically present with rapid-onset earache (otalgia), irritability in infants, and fever. On otoscopy, the hallmark is a red, bulging, and opaque tympanic membrane (TM) with loss of normal light reflex. If the TM ruptures, otorrhoea (ear discharge) occurs, often followed by an immediate relief of pain. Red flags suggesting complications include post-auricular swelling/erythema (mastoiditis), severe headache or meningism (intracranial spread), and facial nerve palsy. OME presents differently; children often exhibit hearing loss, speech delay, or behavioural issues rather than pain. Otoscopy in OME shows a retracted TM, which may appear amber or cloudy, with visible fluid levels or bubbles. The 'No-Stick' test (lack of mobility on pneumatic otoscopy) is diagnostic. AOM can lead to chronic otomastoiditis or cholesteatoma if not managed correctly. Assessment of speech development and educational progress is vital in children with chronic OME. Adult-onset unilateral OME is a 'red flag' and mandates urgent referral to rule out nasopharyngeal carcinoma obstructing the eustachian tube orifice.

- Bedside: Otoscopy is the primary diagnostic tool. Digital otoscopy or pneumatic otoscopy (to assess TM mobility) is ideal.
- Audiology: Pure tone audiometry and tympanometry in children with suspected OME (Tympanometry will show a Type B - flat trace).
- Swabs: Micro-suction or ear swabs for culture and sensitivity if otorrhoea is present or if infection is recurrent.
- Imaging: CT or MRI of the petrous temporal bone and brain only if intracranial or intratemporal complications (e.g., mastoiditis, brain abscess) are suspected.
- Specialty: Urgent 2-week-wait (2WW) referral for nasendoscopy in adults with persistent unilateral glue ear.

Conservative: Reassurance and regular paracetamol or ibuprofen for pain (NICE NG91). A 'no antibiotic' or 'delayed antibiotic' strategy (after 3 days) is recommended for most. Medical: Immediate antibiotics (Amoxicillin 500mg TDS for 5 days or 125-250mg for children) if: systemically very unwell, high risk of complications, <2 years with bilateral AOM, or AOM with otorrhoea. Second-line: Co-amoxiclav. If penicillin-allergic: Clarithromycin or Erythromycin. For OME: Active observation for 3 months. Autoinflation (e.g., Otovent balloon) can be used. Surgical: If OME persists for >3 months with significant hearing loss (>20–30dB), refer for grommet insertion (tympanostomy tubes) +/- adenoidectomy. Emergency management: Admit for IV antibiotics and possible cortical mastoidectomy if mastoiditis is diagnosed.