Acute otitis media

• Earache (younger children may pull, tug or rub their ear to signify this)

• Other symptoms: fever, irritability, crying, loss of appetite, cough or a runny nose or congestion (since acute otitis media may be a complication of the common cold)

• Tympanic membrane could be red/yellow/cloudy and bulging or perforated with discharge evident

• Ear wax impaction and otitis externa are discussed under separate headings

• No improvement has been seen within 3 days or there has been deterioration

• Anyone requiring immediate specialist assessment or immediate antibiotics such as: people with a severe systemic infection; people with suspected complications such as mastoiditis, intracranial abscess; people at increased risk of complications such as those with immunosuppression, heart, kidney or liver disease; children aged less than 3 months; children aged 3-6 months with a temperature of 39 degrees C or more; those with otorrhoea; children aged less than 2 years with bilateral infection

• Suspected meningitis/meningococcal septicaemia: purpuric rash that does not fade following the glass test. Infants and babies may present with a high fever; loss of consciousness; blank expression; vomiting and loss of appetite; high-pitched screaming or whimpering; floppiness, a dislike of being held; and/or a tense or bulging fontanelle. Older children and adults may present with fever, vomiting, stiff neck, photophobia, headache, muscular pains, convulsions, stomach cramps, confusion

• Patients with recurrent symptoms/episodes

• The usual course of acute otitis media is about 3 days but can be up to 1 week. There should be some improvement within 3 days. If symptoms are not improving within this time, or if there is a significant worsening of symptoms at any time, refer for further investigation/potential initiation of antibacterial therapy

• Adequate fluid intake and rest

• Monitor for improvement/deterioration of the patient (particularly if a child)

• Provide correct advice about antibiotics (see below and note that in many cases they are not required because they are likely to have limited difference to symptoms, have side-effects and contribute to the wider problem of antibiotic resistance)

• Treat pain and fever with paracetamol or ibuprofen (paracetamol currently has a better safety profile) NB see the heading 'fever' for comprehensive advice on fever management in children which involves using antipyretic medication only when the child is also distressed
• Pregnancy: unlikely to be something that is encountered in practice. The main difference in the management strategy is that if analgesia required, do not recommend ibuprofen and check individual paracetamol products are licensed for use prior to sale
• A recent Cochrane Systematic Review concluded that probiotics may prevent acute otitis media in children not prone to it (but caution is warranted in interpreting the results due to inconsistency of subgroup analyses). Probiotics decreased the proportion of children taking antibiotics
• See eMC for prescribing information on phenazone and lidocaine (Otigo^®) ear drops. In the UK, these are a prescription-only option

NICE guidance about antibiotics

• 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: NICE advocates an immediate antibiotic prescription
• For people who may be more likely to benefit from antibiotics (those with otorrhoea, or those aged less than 2 years with bilateral infection), NICE options are: no antibiotic prescription (with a safety net about deterioration or no improvement after 3 days); a back-up antibiotic prescription (with a safety net about deterioration or to start taking if no improvement within 3 days); an immediate antibiotic prescription (with a safety net about deterioration)
• For people who may be less likely to benefit from antibiotics, NICE options are: no antibiotic prescription (with a safety net about deterioration or no improvement after 3 days) or a back-up antibiotic prescription (with a safety net about deterioration or to start taking if no improvement within 3 days)