Download 1.0 Aims and scope of this policy

Acute Otitis Media in Children
Summary statement: How does the document
support patient care?
The purpose of this policy is to provide evidence
based guidance for staff on Acute Otitis Media in
Children
Staff/stakeholders involved in development:
Job titles only
ST1
Division:
Women & Child Health
Department:
Paediatrics
Responsible Person:
Chief of Service
Author:
Laura Whitmarsh, Dr M.Linney
For use by:
All clinical staff involved in prescribing and
administering intravenous (IV) fluids to paediatric
patients under the age of 16 years.
Purpose:
This guideline is to aid staff in the diagnosis and
management of children with acute otitis media in the
hospital
This document supports:
Standards and legislation
NICE clinical guidance
Key related documents:
Tonsillitis in children 2009
Paediatric Consultant
Feverish illness in children: assessment and initial
management in children younger than 5 years.
NICE clinical guideline 47 (2007)
WSHT Paediatric antimicrobial policy accessed 2012
Approved by:
Joint Paediatric Guidelines Group
Divisional Governance/Management Group
Approval date:
October 2012
Ratified by Board of Directors/ Committee of
the Board of Directors
No Applicable – Divisional ratification only required
Ratification Date:
No Applicable – Divisional ratification only required.
Expiry Date:
November 2015
Review date:
August 2015
If you require this document in another format such as Braille, large print,
audio or another language please contact the Trusts Communications Team
Reference Number:
To be added by the Library
Acute Otitis Media in Children Guideline
Version 2
Page 1 of 8
Oct 2012
Version
date
Author
Status
1.0
Oct 2012
Dr M Linney
Live
Comment
2.0
3.0
4.0
Acute Otitis Media in Children Guideline
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Oct 2012
INDEX
1.0
2.0
3.0
4.0
5.0
6.0
7.0
Aims and Scope of Policy
Key points
Assessment
Differential Diagnosis
Complications
Management
Auditable Standards
References
Acute Otitis Media in Children Guideline
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4
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5
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1.0 Aims and scope of this policy
This guideline is based on the NICE clinical guidance “respiratory tract infections and
antibiotic prescribing and recent reviews/meta analysis of acute otitis media. It aims to aid
diagnosis and management of children with acute otitis media on Howard Ward, CAU and
children’s A&E
2.0 Key points
Acute Otitis media (AOM) is a common infection in childhood with up to 20% of under 4 year
olds have one episode a year. It usually presents with otalgia, fever and hearing impairment
or irritability. It is normally a self limiting illness with 80% of affected individuals having an
improvement after 3 days. Bacteria cause the majority of cases, the most common ones are
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Group A
streptococcus, Staphylococcus aureus.
Inappropriate antibiotic prescribing is likely to lead to drug related adverse incidents,
increased prevalence of drug resistance and lead to an increase in presentations to primary
care for minor illnesses.
Main policy
3.0
Assessment
Take a full history and perform examination to:
1. To identify relevant co-morbidities.
2. Gain an understanding of parents concerns and expectations to establish best policy
for prescribing.
3. Examine to confirm diagnosis and identify any signs of complications (i.e. mastoiditis)
Clinical features consistent with AOM are:
 Sudden onset of symptoms (usually preceded by URTI):
Earache is the most common symptom. Fever, hearing loss/difficulty, tugging on ears
or rubbing ears, irritability, restlessness at night are also sometimes associated with
AOM

Signs of AOM or middle ear effusion:
Examination with an otoscope will reveal, bulging tympanic membrane, change in
colour of tympanic membrane to yellow or red, there may be a rupture of the
membrane with pus seen in the ear canal (symptoms are often relieved at this time).
It is important to fully examine the child to help differentiate with other diagnosis as
detailed below and look for complications.
It should be noted that children especially those under 2 years of age may present with
systemic features rather than localising features.
Acute Otitis Media in Children Guideline
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4.0
Differential diagnosis:
1. Mastoiditis-examine for erythema swelling and tenderness in the peri auricular area.
Classically have protruding ear on affected side. A potentially serious complication of
AOM
2. Impacted ear wax
3. Otitis media with effusion(part of the same spectrum of disease)
4. Otitis externa – more common in adults and often bilateral
5. Otitic barotrauma (history very important for this)
6. Referred pain-more common in older patients check for jaw dental spine symptoms
or signs. Less likely if otalgia is bilateral.
5.0
Complications
Common complications
1. Hearing loss-most common, conductive hearing defect, usually transient-whilst
middle ear effusion persists may be up to 60db loss.
2. Perforated tympanic eardrum
3. Otitis media with effusion-common, 10% of children will have at 3 months, the
younger the child the more likely that it will be persistent.
4. Otitis externa
5. Vestibular disturbance and imbalance
Rare but serious complications
1. Mastoiditis-less than 1 in 1000 untreated children. May lead to cerebral complications
such as abscess or sinus thrombus.
2. Cholesteatoma – cystic like structure of stratified squamous epithelium. Grows by
eroding into bone. May lead to invasion of temporal bone leading to meningitis and
cerebral abscess
3. Facial paralysis-may be due to presence of effusion or may represent associated
mastoiditis
4. Labyrinthitis due to spread of the infection to the labyrinth may be acute or chronic
5. Sensorineural hearing loss-due to spread through the round window usually
permanent.
6. Intracranial sepsis – these patient will require urgent ENT referral and full
assessment including bloods
If you are a suspicious of a serious complication then involve senior medical staff. (registrar
or consultant of the week) at an early stage.
6.0
Management
1. Reassurance. Give advice about; Diagnosis, Natural history (4 days otitis media)
2. Analgesia & Antipyretics
3. Antibiotics.
i.
No antibiotics in acute otitis media this is appropriate for the majority of cases.
ii.
Delayed prescriptions maybe required when there are parental concerns which
you are unable to alleviate. Give reassurance that antibiotics are not required
Acute Otitis Media in Children Guideline
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immediately as are unlikely to shorten course of illness and have side effects such
as diarrhoea, vomiting, rashes. If giving a delayed prescription then give advice
when they should get it i.e. significant worsening or no improvement inline with
the natural history
iii.





iv.
Consider Immediate Antibiotics in :
Bilateral AOM <2 years old
AOM with otorrhoea
Features of systemic illness
Symptoms or signs of complications (as detailed above)
o If serious complication suspected-: Involve senior paediatrician, resuscitate
as necessary, perform blood tests for CRP, FBC and film, U&Es LFTs
blood cultures PCR for pneumococcal and meningococcal. Start IV
Cefotaxime
Co-morbidity – lung (including CF) heart, renal or liver disease,
immunosuppression, ex-premature young children.
Which antibiotics and length of treatment
A five day course should be prescribed. Amoxicillin is first line, response is expected
within three days-improvement in pain, resolution of pyrexia and irritability. If there is
no response then they should be evaluated for occurrence of the supportive
complications and an alternative antibiotic should be prescribed. Persistence of
middle ear effusion doesn’t suggest treatment failure. In treatment failure augmentin
may be used. clarithromycin should be used for penicillin allergic patients.
4. Decongestants and Anti histamines are not recommended, as the significant side
effects outweigh the limited benefits
5. Urgent ENT referral for:
 Sudden onset of severe hearing loss (not associated with perforation)
 Sudden dizziness and nystagmus
 Progression to mastoiditis/ serious complications
6. Elective referrals to ENT for:
 Persistent effusion discharge or perforation-for more than 6 weeks
 More than 3 episodes in 6 months or 4 in 12 months of AOM and proven hearing
loss
 Persistent effusion and impaired hearing for 3-6 months.
Acute Otitis Media in Children Guideline
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Flow Diagram For Management Of AOM
No
Clinical features of AOM?
Yes
Identify alternative
diagnosis and treat
appropriately
Yes
Signs of serious
complications?
Involve senior paediatrician
Resuscitate if necessary
Blood U&Es, co-ag, FBC, LFTs, CRP Cultures
IV antibiotics-Cefotaxime
NO
Give advice on natural course and
management of symptoms.
Any of the following present?
 Bilateral AOM <2 years old
 AOM with otorrhoea
 Co- existing tonsillitis with 3 or
more Centor criteria (tonsilar
exudates, tender anterior
lymphadenopathy, history of
fever and absence of cough – see
tonsillitis policy.)
 Features of systemic illness
 Symptoms or signs of
complications (as detailed above)
o If serious complication
suspected-: resuscitate as
necessary, perform blood
tests for CRP, FBC and
film, U&Es LFTs blood
cultures PCR for
pneumococcal and
meningococcal. Start IV
Cefotaxime
 Co-morbidity – lung (including
CF) heart, renal or liver disease,
immunosuppression, exYes
premature young children.
Urgent referral to ENT specialists.
No
Parental expectation or concern despite
reassurance.
yes
Consider delayed
antibiotic
prescription and
advice.
No
Reassurance and
advice, no
antibiotics
prescribed.
Consider Immediate AntibioticsAmoxicillin for 5 days or
clarithromycin if penicillin allergic
Acute Otitis Media in Children Guideline
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7.0
Auditable Standards
http://www.nice.org.uk/nicemedia/pdf/RespiratoryTractInfectionsAuditSupport.doc
References:
NICE clinical guideline 69: Respiratory Tract infections-antibiotic prescribing. Issue date July 2008
Infectious Diseases and Immunization Committee, Canadian Paediatric Society (CPS) Paediatrics & Child
Health 1998; 3(4): 265-267. Reference No. ID 97-03
Illustrated textbook of paediatrics, 2nd edition. Tom Lissauer, Graham Clayden Mosby 2001
Institute for clinical systems improvement, Diagnosis and Treatment of Otitis Media in
Children Ninth Edition/January 2008
Coleman C, Moore M. Decongestants and antihistamines for acute otitis media in children. Cochrane
Database of Systematic Reviews 2008, Issue 3. Art. No.: CD001727. DOI:
10.1002/14651858.CD001727.pub4.
BNF for children. 2008 edition. BMJ Group London. 2008
Feverish illness in children: assessment and initial management in children younger than 5
years. NICE clinical guideline 47 (2007). Available from: www.nice.org.uk/CG047
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