Acute otitis media (middle ear infection): symptoms and care

NICE Clinical Knowledge Summaries define acute otitis media as inflammation of the middle ear with fluid behind the eardrum, accompanied by the rapid onset of the symptoms and signs of an ear infection. The NHS explains that the middle ear sits behind the eardrum and is connected to the back of the nose by the eustachian tube, which is why infections often follow colds, and that middle ear infections usually affect children.

Both viruses and bacteria can be responsible, and NICE notes it is difficult to distinguish between the two, since both are often present together. The infection is self-limiting in most people.

CKS reports that acute otitis media most commonly affects children from birth to 4 years of age. Those more likely to be affected include children exposed to passive smoking, those who attend daycare or nursery, those who are formula-fed and those with differences in the structure of the face and skull such as a cleft palate. In adults the condition is less common.

• The NHS says middle ear infection is caused by viruses such as those behind colds and flu, and that it affects the eustachian tube linking the middle ear to the back of the nose.

• CKS lists avoiding passive smoking, dummy use and flat, lying-down feeding among the measures that help prevent recurrent episodes in children.

• For adults, avoiding smoking and passive smoking is the measure CKS lists to help prevent recurrence.

In older children and adults, acute otitis media typically presents with earache. The NHS lists the wider symptoms of an ear infection: pain inside the ear, a high temperature, difficulty hearing, discharge from the ear and a feeling of pressure or fullness. Babies and young children may rub or pull at the ear, not react to some sounds, be irritable or restless, be off their food, or keep losing their balance.

CKS adds that younger children may show nonspecific features such as fever, crying, poor feeding, restlessness, cough or a runny nose. On examination, a clinician looking with an otoscope sees an eardrum that is distinctly red, yellow or cloudy and sometimes bulging.

NICE guidance on antimicrobial prescribing in acute otitis media recommends regular paracetamol or ibuprofen for pain, at the right dose for the age or weight of the child and using maximum doses for severe pain, and advises explaining that decongestants and antihistamines do not help symptoms. The NHS adds that children under 16 should not take aspirin, and suggests wiping away discharge with cotton wool, keeping water and shampoo out of the ear and not putting anything inside it.

Eardrops containing a local anaesthetic and a painkiller can be considered when an immediate antibiotic prescription is not given and there is no perforation or discharge; treatment should be reviewed if symptoms are not better within 7 days or worsen at any time. Parents are told what the usual course is: about 3 days, sometimes up to a week.

The NICE guideline explains that most children get better within 3 days without antibiotics, that antibiotics make little difference to pain after the first 24 hours, and that they make little difference to common complications such as short-term hearing loss, a perforated eardrum or repeat infection. They can also cause side effects, particularly diarrhoea and nausea. For this reason, the options for many children are no antibiotic or a back-up prescription, which is used only if symptoms have not started to improve within 3 days or if they worsen significantly.

There are groups in whom antibiotics are more likely to help. NICE identifies children of any age with discharge from the ear, and children under 2 with infection in both ears, as more likely to benefit, and recommends an immediate antibiotic prescription for anyone who is systemically very unwell, has signs of a more serious illness or is at high risk of complications. CKS states that where an antibiotic is required, a 5 to 7 day course of amoxicillin is the recommended first choice, with clarithromycin or erythromycin as alternatives for penicillin allergy. Dosing is individual and set by the prescriber.

Complications of acute otitis media include recurrent infection, hearing loss, a perforated eardrum and, rarely, mastoiditis, meningitis, brain abscess, venous sinus thrombosis and facial nerve paralysis. CKS says people with a severe systemic infection, suspected complications, or babies younger than 3 months with a temperature of 38C or more should be admitted to hospital for immediate specialist assessment.

The NHS advises that a child aged 1 to 17 with a suspected ear infection can see a pharmacist, who can give the same treatments as a GP. A GP is advised if the child is under 12 months, earache has not improved after 3 days, or infections keep recurring. Urgent help from NHS 111 or an urgent GP appointment is advised if there is a very high temperature, swelling around the ear, fluid coming from the ear, new hearing loss, vomiting or dizziness, if a child under 12 months has earache in both ears, or if the person has diabetes, a heart, lung, kidney or neurological condition or a weakened immune system.

CKS lists measures that reduce the chance of recurrence. In children these include avoiding passive smoking, limiting dummy use, avoiding flat, lying-down feeding and making sure the childhood pneumococcal vaccinations are complete. In adults, avoiding smoking and passive smoking is advised. The NHS also suggests making sure all childhood vaccinations are up to date and trying not to give a child a dummy after 6 months of age.

Children who keep having infections, or who are left with persistent fluid behind the eardrum and trouble hearing, may be referred to ear, nose and throat services. That fluid, known as glue ear, is a separate condition that can follow an episode of acute otitis media. Private ENT and audiology services offer hearing tests and assessment for the same problems.