Paediatric Pathways

Acute otitis media (AOM) and mastoiditis pathway for children presenting to hospital

DIFFERENTIALS

Acute presentation of ear pain (otalgia), discharge (otorrhoea) +- fever. AOM diagnosis is strengthened by the presence of a bulging tympanic membrane, air-fluid level behind the tympanic membrane, tympanic membrane perforation and/or discharge in the ear canal (although discharge only occurs in AOM if there is a tympanic perforation). Presence of fluctuant post auricular swelling and/or protrusion of the pinna suggest possible mastoiditis.

Otitis media has similar symptoms to acute otitis externa but important to differentiate between the two because AOM can lead to intracranial complications.

 

CLINICAL SIGNS OTITIS EXTERNA OTITIS MEDIA
Ear pain Yes Yes, often improved when discharge commences
Discharge Scanty Mod/severe Mucopurulent
Hearing Later onset muffled Early onset
Preceding URTI No Often
Tender ear canal Yes, very No
Periauricular swelling Yes in severe secondary to soft tissue cellulitis No unless mastoiditis
Canal swelling Yes No
Ear drum Can be difficult to visualise due to canal debris Red bulging, oedematous, perforated with mucopus pulsating through
Associated with intracranial complications No (unless immuno- compromised) Yes

INVESTIGATIONS

Evaluate severity of infection:
MILD = systemically well or fever but haemodynamically stable
MODERATE = systemically unwell including fever AND persisting tachycardia / tachypnoea
SEVERE = presence of any red flags*

If MILD infection, no investigations required.
If MODERATE / SEVERE infection, for FBC, CRP and blood culture +- ear swab if discharge/pus in canal.
If SEVERE infection, for urgent senior review and ENT input. If mastoiditis, consider contrast CT of petrous bones or if intracranial complications suspected, consider MRI brain/petrous bones$.

*RED FLAGS:

URGENT senior review and ENT input if:

  • Signs of extra-cranial complications:
    • Features of mastoiditis
  • Intracranial infection can occur in absence of mastoiditis. Signs include:
    • Increasing drowsiness
    • Meningism / irritability
    • Severe headache persisting despite regular analgesia (ibuprofen and paracetamol) or worse on lying down / in morning
    • Persistent vomiting
    • Severe retroorbital pain
    • New onset squint or diplopia - covering up one eye
    • Deteriorating vision - complaining of blurred vision
    • New limb weakness – may exhibit change of hand preference
    • Unsteady gait or coordination issues
    • Pain beyond the ear, extensive headache or facial pain
  • Haemodynamic instability / sepsis (may require urgent source control) or signs of toxic shock syndrome (shock, mucosal erythema, rash, GI symptoms)

If signs of intracranial infection or mastoiditis, consider urgent neuro-otological imaging (CT +/- MRI)

MANAGEMENT

MILD infection – optimise analgesia (paracetamol or ibuprofen).

Only consider antibiotics if symptoms not improving after 3 days, otorrhoea (not due to otitis externa), immunosuppression or AOM in a child <6 months of age.1 If aged 6/12mths-2 years, start Abx if bilateral AOM, otorrhoea or symptoms not improving after 3 days.5

If antibiotics indicated, oral antibiotics as per local/national guidelines.1
If AOM requiring treatment in a child with tympanostomy tubes, treat with non-ototoxic topical Abx rather than oral Abx.4
Total duration of treatment 5 days ( consider 7 days for recurrent infection)1-3
Provide verbal and written safety netting information
If no improvement despite >72 hours of adequate oral Abx ((check dose and adherence), consider 2nd line oral Ab therapy as per local/national guidelines.1

MANAGEMENT

MODERATE infection – consider initial management with IVAbx as per local empirical antibiotic guidelines.

If persisting fever/no clinical improvement despite 48 hours antibiotics (check dose and adherence), arrange ENT review.

If development of red flags, for urgent ENT review and consider urgent neuro-otological imaging (contrast CT or MRI)$

Consider ambulation8 on IVAbx from ED / assessment unit (admission avoidance) unless:

Ensure robust clinical governance systems and documentation in place for children being ambulated
Daily review required and provide verbal and written safety netting information

IV to oral switch when:

  • Clinically improving +- improving inflammatory markers
  • Apyrexial
  • If source control (mastoidectomy), then consider early IV to oral switch.6
  • Choice of oral antibiotics as per local/national guidelines.1 Total duration of treatment (IV+oral)=7 days (14 days if mastoiditis). Seek paeds ID/micro advice if intracranial infection.

MANAGEMENT

SEVERE infection – start IVAbx as per local empirical antibiotic guidelines

Urgent ENT review and consideration of neuro-otological imaging (contrast CT or MRI)

$If neuro-otologial imaging performed, ENT review of imaging findings:

  • AOM but no intracranial complication - consider continuing IV antibiotics +/- grommet
  • Acute mastoiditis – drainage of mastoid +/- grommet if clinical or radiological evidence of subperiosteal access or other red flags
  • Acute ongoing simultaneous ENT infection may require grommet insertion +/- cortical mastoidectomy. See BSO Guideline.

Management of Intracranial complications depends on type and requires ENT, neurosurgical and infectious diseases input7:

  • Intracranial abscess may require urgent drainage depending on site, size and symptoms
  • Intracranial sinus thrombosis may need neurology input for consideration of anticoagulation

The development of this pathway involved a systematic review of the literature, collaborative development of the pathway with relevant national groups followed by formal national consultation. For more information, click here

REFERENCES
  1. Venekamp RP, Sanders SL, Glasziou PP et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2015; https://dx.doi.org/10.1002/14651858.CD000219.pub4: CD000219.
  2. Venekamp RP, Damoiseaux RA, Schilder AG. Acute otitis media in children. BMJ Clin Evid 2014; 2014.
  3. NICE (National Institute for Health and Care Excellence). Otitis media (acute): antimicrobial prescribing. NICE guideline [NG91]. Available at https://www.nice.org.uk/guidance/ng91. 2018.
  4. van Dongen TMA, van der Heijden GJMG, Venekamp RP et al. A trial of treatment for acute otorrhea in children with tympanostomy tubes. N Engl J Med 2014; 370: 723-33.
  5. Hoberman A, Paradise JL, Rockette HE et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med 2011; 364: 105-15.
  6. Moore JA, Wei JL, Smith HJ et al. Treatment of pediatric suppurative mastoiditis: is peripherally inserted central catheter (PICC) antibiotic therapy necessary? Otolaryngol Head Neck Surg 2006; 135: 106-10.
  7. Lording A, Patel S, Whitney A. Intracranial complication of ear, nose and throat infections in childhood. Journal of ENT Masterclass 2017; 10: 64-70.
  8. Patel S, Abrahamson E, Goldring S et al. Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement. J Antimicrob Chemother 2015; 70: 360-73.