Acute Otitis Media and Mastoiditis in adults
|Next review: 10/03/2026|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2023|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for the management of Acute Otitis Media and Mastoiditis in Adults
Acute Otitis Media and Mastoiditis in adults
Summary/Quick reference guide for acute otitis media (AOM)
Uncomplicated AOM is defined as: Mild pain of <4 days duration and an absence of severe systemic symptoms, with a temperature of less than 39°C and no ear discharge.
Follow algorithm for selection of patients requiring antimicrobial therapy
Acute otitis media (AOM) is usually a short-term inflammation of the middle ear, characterised by the rapid onset of one or more signs or symptoms of acute inflammation in the middle ear such as earache and fever, in the presence of a middle-ear effusion. It is often preceded by upper respiratory symptoms, including a cough and rhinorrhoea [Bluecastle et al, 2002; SIGN, 2003; Rovers et al, 2004].
Acute otitis media (AOM) is one of the most common complaints seen in UK primary care but AOM is relatively uncommon in adults, with over 75% of cases occurring in children aged under 10 years [SIGN, 2003].
Note: AOM is primarily a condition that affects young children and infants. The overwhelming majority of research on AOM has been performed in these groups. This guideline refers to management of adults. It is generally assumed that AOM in adults behaves and responds in the same way as in children. The main difference is in the outcomes related to loss of hearing which can affect a child’s language development. In this way the outcomes of this disease can be different for adults and children but the disease itself does not appear to be different.
Complicated AOM is defined as the presence of:
Meningitis and brain abscesses should be managed according to LTHT guidelines with ENT input as required.
See separate Trust guideline for management of children with AOM.
Box 1. Risk factors associated with treatment failure or adverse outcome [Evidence level B]
Recommendation: offer analgesia if pain is present. For most, this is the mainstay of treatment. [Evidence level C]
|Empirical Antimicrobial Treatment|
Recommendation: Antibiotics should not be routinely prescribed for uncomplicated AOM. Discuss and reassure the individual on the benefits of and drawbacks of using antibiotics for AOM. Evidence level A
About 80% of episodes of acute otitis media (AOM) in patients will resolve within 3 days without treatment [Glasziou et al, 2004]. The need for admission, the need for various investigations, the need for and choice of antimicrobial therapy and the route of administration of antimicrobials should be influenced by the severity of infection and the presence of risk factors for an adverse outcome. An algorithm to guide the appropriate treatment pathway is included. As with all guidelines, this is no substitute for clinical judgment and if there are concerns about the appropriateness of a suggested pathway these should be discussed with a senior colleague.
The algorithm is a synthesis of evidence which comes from levels A-D.
Table 1. Empirical oral antimicrobial regimens for acute otitis media
*True penicillin allergy – i.e immediate type IgE mediated reaction including angio-oedema, acute cardiovascular or respiratory collapse, whole body or urticarial rash.
Table 2. Empirical intravenous antimicrobial regimens for acute otitis media and mastoiditis.
*True penicillin allergy – i.e immediate type IgE mediated reaction including angio-oedema, acute cardiovascular or respiratory collapse, whole body or urticarial rash. #Adjust doses according to renal function. Where combinations of risk factors exist discuss with Microbiology or Infectious Diseases.
|Directed Antimicrobial Treatment (when microbiology results are known)|
If microbiological diagnosis becomes available e.g. via Blood Cultures or pus samples, therapy should be altered according to susceptibilities or discussed with a microbiologist.
|Duration of Treatment|
5 days therapy is sufficient for most cases of otitis media.
Immunocompromised patients may need more prolonged antimicrobial therapy. Discuss with microbiology on a case by case basis if required.
In severe infection a minimum 10 - 14 day total course is recommended. [Evidence level D]
In acute mastoiditis, there is very little evidence to support a particular duration of therapy and duration will be affected by the need for surgery. A 4 week total course is recommended in the first instance. [Evidence level D]
|Switch to oral agent(s)|
In severe infection, when intravenous therapy has been commenced, switch to oral antimicrobials can usually be done safely after 48 hours, provided that local and systemic signs of infection are resolving and any co-morbidities are stabilised.
More prolonged intravenous therapy may be required for mastoiditis. Oral switch for mastoiditis is Co-amoxiclav 625mg 8-hourly.
|Please contact microbiology if the patient is not responding to the recommended antimicrobial regimens.|
Acute Otitis Media and Mastoiditis
|Target patient group:||Adults with acute otitis media|
|Target professional group(s):||Secondary Care Doctors
Secondary Care Nurses
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A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus.
Improving Antimicrobial Prescribing Group
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