Acute Otitis Media

AOM is infection of the middle ear.  It is common, especially in young toddler-age children (mainly because of an underdeveloped Eustachian tube and immune system).  It is quite common for an attack of AOM to occur after an upper respiratory tract infection/throat infection


  • Viral (seem to be most common- less serious but can cause secondary bacterial infection)
    • Respiratory syncytial virus (RSV)- usually only in children (and immunodeficient people).
  • Bacterial (4 main players)
    • Streptococcus pneumoniae (most common- 35-50%)
    • Haemophilus Influenzae (20-25%)
    • Moraxella catarrhalis (10-15%)
    • Streptococcus pyogenes (Group A) (most aggressive form)
      • Others include Staph aureus, Pseudomona and Strep viridans


  • In adults/older children- ear pain is the main feature and is described as a throbbing, gradually worsening pain which may or may not be relieved by a perforated membrane.
    • Hearing loss can be marked but is usually ok due to a normal contralateral ear
  • In younger children, ear tugging, unremitting fever, irritability and hearing loss (not responsive on one side) usually indicate AOM.  HOWEVER, teething and throat infections may present similarly.

On Examination

  • The patient may have a temperature (pyrexia)
  • The area around the ear (including the ear) may be tender on movement
  • At otoscopy
    • the membrane may appear stretched with a loss of ‘lustre’ and loss of light reflex
      • as a result of the ‘fullness’- the handle of the malleus can become more vertical or be obscured by the swelling
    • the membrane may appear injected (blood vessel growth into the membrane)
    • the membrane and surrounding area may be erythematous/purple and the outer layer of the membrane can desquamate
      • to cause a blood-stained serous discharge
  • If the membrane has perforated, a more purulent discharge may be present

NB Viral AOM usually has less severe signs, although patients may present with a more flu-like illness.  These usually resolve spontaneously or cause secondary bacterial infection, so should be carefully followed up to double check for this.


Early treatment with antibiotics is important to prevent further complications.

  • In adults (where Streptococcal infection predominates), the majority of cases can be treated amoxicillin although most adult cases will respond to penicillin V
  • In children (where H influenzae infection is more common), amoxicillin is the recommended antibiotic
  • Where penicillin allergy (/2nd line)- erythromycin
  • Where eczema is the probably cause, topical steroid may help

A swab should be taken, where possible, for culture and sensitivities.  Once the results of these are available, antibiotic use should be guided by them.  (e.g. co-amoxiclav may be required for Moraxella infection).

Analgesia may be required, and paracetamol may be useful for this, especially in young children who also have a temperature.


AOM infection does have the postential to spread to other areas of the body:

  • Intratemporally– mastoiditis; facial nerve palsy; acute labyrinthitis; petrositis; chronic otitis media
  • Intracranially– meningitis; encephalitis; brain abscess; sigmoid sinus thrombosis
  • Systemically– Bacteraemia, septic arthritis or bacterial endocarditits

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