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:
- Clinical risk factors: haemodynamically unstable, risk of dehydration, requirement for drainage
- Social / caregiver risk factors
Ensure robust clinical governance systems and documentation in place for children being ambulated
Daily review required and provide verbal and written safety netting information - otitis media or mastoiditis
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
- 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.
- Venekamp RP, Damoiseaux RA, Schilder AG. Acute otitis media in children. BMJ Clin Evid 2014; 2014.
- 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.
- 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.
- 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.
- 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.
- Lording A, Patel S, Whitney A. Intracranial complication of ear, nose and throat infections in childhood. Journal of ENT Masterclass 2017; 10: 64-70.
- 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.
Access e-Learning course:
This course has been created to supplement the BSAC Paediatric Pathways site. The course follows the pathway for treating otitis media/mastoiditis but does so through a case study. The aim of this course is to familiarise yourself with the pathway and how the pathways are put in place practically.
