Acute Otitis Media and Mastoiditis in adults

Publication: 01/03/2010  
Next review: 10/03/2026  
Clinical Guideline
CURRENT 
ID: 5424 
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.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the management of Acute Otitis Media and Mastoiditis in Adults

  • Treatment Algorithm
    		•
    Summary
    Acute Otitis Media and Mastoiditis in adults

    Summary/Quick reference guide for acute otitis media (AOM)

    History
    • Adult patients [>16] with new/rapid onset earache and associated loss of hearing.
    • Often preceding history of upper respiratory symptoms including cough and rhinorrhoea.
    • Assess risk factors for adverse outcome/poor response to therapy [Box 1].

    Examination
    • Cerumen (wax) or debris blocking the canal should be removed under direct vision by a competent person.
    • Otoscopic appearances of AOM: bulging tympanic membrane with loss of landmarks; changes in membrane colour (typically red or yellow); perforation, discharge of pus.
    • Note appearance of ear canal and pinna.
    • Palpate mastoid for tenderness.
    • Note any cervical lymph node enlargement.
    • Carry out severity assessment including MEWS score, follow algorithm
    • Assess for signs of meningitis or altered conscious level (using Glasgow Coma Scale) if indicated.

    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.
    Complicated AOM is defined as the presence of: severe pain, perforated eardrum and/or purulent discharge, bilateral infection mastoiditis (pain and inflammation of the mastoid cavity), labyrinthitis, meningitis, intracranial sepsis, or facial nerve palsy

    Investigations
    • Blood cultures [2 sets] prior to starting antibiotics only in severe infection (sepsis, severe sepsis, septic shock).
    • FBC, CRP, U&E, LFTs if intravenous antimicrobials planned.
    • Pus sample (see full Investigations section)

    Non-antimicrobial treatment
    Offer analgesia if pain is present. For most, this is the mainstay of treatment.
    • Paracetamol 1g 6-hourly is the preferred treatment.
    • Ibuprofen 400mg 8-hourly is an alternative to paracetamol (if no contraindications).

    Antimicrobial Treatment
    Antibiotics should not be routinely prescribed for uncomplicated AOM. Discuss and reassure the individual on the benefits of and drawbacks of using antibiotics.

    Follow algorithm for selection of patients requiring antimicrobial therapy
    See Table 1 for Empirical oral antimicrobial regimens.
    See Table 2 for Empirical inpatient intravenous antimicrobial regimens

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    Background

    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.

    Microbiology
    The cause of AOM may be of viral or bacterial origin, although studies have shown that in about 25% of cases of AOM a pathogen was not identified.  Viruses are present in about 25% of people with AOM and often precede or coexist with a bacterial infection [Klein, 1995]. Viral acute otitis media is most commonly caused by the respiratory syncytial virus or rhinovirus [Rovers et al, 2004].
    The main bacteria responsible for AOM (cultured from middle-ear effusions obtained from needle aspirates) are as follows:

    • Streptococcus pneumoniae is the most common cause, accounting for nearly 40% of infections.
    • Haemophilus influenzae is involved in about a quarter of people with AOM. It is more common in younger children.
    • Moraxella cattarhalis accounts for about 10% of infections, and is increasing in prevalence. Strains are now usually resistant to Amoxicillin electronic Medicines Compendium. [Klein, 1995; Rovers et al, 2004]

    Definitions
    Uncomplicated AOM is defined as:
    Mild pain of less than 72hours duration and an absence of severe systemic symptoms, with a temperature of less than 39°C and no ear discharge.

    Complicated AOM is defined as the presence of:
    Severe pain, perforated eardrum and/or purulent discharge, bilateral infection, mastoiditis (pain and inflammation of the mastoid cavity), labyrinthitis, meningitis, intracranial sepsis, or facial nerve palsy (see below).

    Complications
    Severe complications such as mastoiditis (infection of the mastoid bone and air cells), labyrinthitis, meningitis, intracranial sepsis, or facial nerve palsy are rare in otherwise healthy patients from developed countries [O'Neill et al, 2006]. The most common of these conditions, mastoiditis, has been found to occur in less than 1 in 1000 children with untreated AOM [Takata et al, 2001].  Rarely (0.7% to 3.2%) intracranial spread causing meningitis or a cerebral abscess can occur. [Verhoeff et al, 2006].  Mastoiditis and other severe complications of AOM are very rare in adults.

    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.

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    Clinical Diagnosis

    History
    Assess local symptoms. Earache is the most common symptom [SIGN, 2003]. Earache may suddenly ease if the tympanic membrane perforates with discharge of pus, presumably due to relief of pressure. Loss of hearing may occur because of the presence of effusion in the middle ear.

    • Assess systemic symptoms of infection such as general malaise, fever, loss of appetite, sweats and chills.
    • Identify any history of previous upper respiratory symptoms including cough and rhinorrhoea [SIGN, 2003].  
    • Assess for risk factors associated with treatment failure or adverse outcome according to Box 1.

    • Adults with serious craniofacial abnormalities
    • Immunocompromised patients
    • Diabetes mellitus
    • Frail/aged >80
    • Treatment failure in the community

    Box 1. Risk factors associated with treatment failure or adverse outcome [Evidence level B]

    Examination

    • Otoscopic appearances typical of AOM include: Bulging tympanic membrane with loss of landmarks. Changes in membrane colour (typically red or yellow). Perforated tympanic membrane with discharge of pus (which may alleviate symptoms)
    • Local spread to surrounding structures e.g. mastoiditis can occur so assess for spreading pain, erythema, tenderness and mild swelling in the post auricular area.  The pinna is classically displaced anteriorly and upward in acute mastoiditis.
    • Assess for signs of systemic sepsis using the Modified Early Warning Score (MEWS) to indicate severity of signs.
    • Intracranial spread. Assess for signs of meningitis or altered conscious level (using Glasgow Coma Scale) if indicated.

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    Investigation

    Acute otitis media is a clinical diagnosis.

    Recommendation: If the tympanic membrane has perforated and pus is present in the ear canal and a patient is being admitted for intravenous antimicrobial therapy or has failed previous antimicrobial therapy send a sample of pus (ideally collected using a sterile syringe (without a needle) into a sterile sample container. [Evidence level C]

    Recommendation: In patients who require intravenous antimicrobial therapy, the following baseline investigations should be performed and repeated according to clinical need: FBC, CRP, U&E and LFTs

    Renal & liver function will influence choice and dose of antimicrobials as well as fluid balance, nutritional support etc. [Evidence level D]

    Recommendation: Two sets of blood cultures should be taken at different times in all patients with severe infection (e.g. severe local infection, severe sepsis, septic shock). [Evidence level B]

    Recommendation: In patients where intracranial spread is suspected please

    See guidelines for meningitis or brain abscess.

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    Treatment
    Non-Antimicrobial Treatment

    Recommendation: offer analgesia if pain is present. For most, this is the mainstay of treatment. [Evidence level C]

    • Paracetamol 1g qds is the preferred treatment.
    • Ibuprofen 400mg tds is an alternative to paracetamol where there are no contraindications.

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    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

    Situation

    1st line therapy

    2nd line therapy

    Duration

    Non pregnant patient

     

     

     

            non penicillin allergic*

    Amoxicillin electronic Medicines Compendium 500mg 8 hourly

    Clarithromycin electronic Medicines Compendium 500mg 12 hourly

    5 days

            penicillin allergic

    Clarithromycin electronic Medicines Compendium 500mg 12 hourly

    Levofloxacin electronic Medicines Compendium 500mg 24 hourly

    5 days

    Pregnant patient

     

     

     

            non penicillin allergic*

    Amoxicillin electronic Medicines Compendium 500mg 8 hourly

    Erythromycin electronic Medicines Compendium 500mg 6 hourly

    5 days

            penicillin allergic

    Erythromycin electronic Medicines Compendium 500mg 6 hourly

    Discuss with microbiology

    5 days

    *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. 

    Situation

    1st line therapy

    Duration

    Oral switch

    Non pregnant patient

     

     

     

          non penicillin allergic*

    Co-amoxiclav electronic Medicines Compendium# 1.2g 8-hourly IV

    48 hour review

    Co-amoxiclav electronic Medicines Compendium# 625mg 8-hourly

          penicillin allergic

    Vancomycin electronic Medicines Compendium# IV plus oral Ciprofloxacin electronic Medicines Compendium# 500mg 12 hourly

    48 hour review

    Discuss with microbiology

    Pregnant patient

     

     

     

          non penicillin allergic*

    Co-amoxiclav electronic Medicines Compendium# 1.2g 8-hourly IV

    48 hour review

    Co-amoxiclav electronic Medicines Compendium# 625mg 8-hourly

          penicillin allergic

    Discuss with microbiology

    48 hour review

    Discuss with microbiology

    *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.

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    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.

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    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]

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    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 electronic Medicines Compendium 625mg 8-hourly.

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    Treatment Algorithm

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    Treatment Failure
    Please contact microbiology if the patient is not responding to the recommended antimicrobial regimens.

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    Provenance

    Record: 5424
    Objective:
    Clinical condition:

    Acute Otitis Media and Mastoiditis
    Target patient group: Adults with acute otitis media
    Target professional group(s): Secondary Care Doctors
    Secondary Care Nurses
    Adapted from:

    Evidence base

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    Evidence levels:
    A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
    B. Robust experimental or observational studies
    C. Expert consensus.
    D. Leeds consensus.

    Approved By

    Improving Antimicrobial Prescribing Group

    Document history

    LHP version 1.0

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