Summary

Otitis Media refers to inflammation of the middle ear cleft. It is divided into two distinct entities: Acute Otitis Media (AOM), which is an acute purulent infection presenting with pain and fever, and Otitis Media with Effusion (OME / Glue Ear), which is a chronic non-purulent collection of fluid causing conductive hearing loss. AOM is one of the most common childhood illnesses, peaking at 6-12 months. Most AOM is viral or self-limiting bacterial, treated with analgesia and a "wait and see" approach. Antibiotics are reserved for high-risk groups. OME is the commonest cause of childhood deafness and speech delay; persistent OME is treated with Ventilation Tubes (Grommets).

Key Facts

• AOM vs OME: AOM = Infection (Pain/Fever). OME = Fluid (Deafness/No Pain).
• Most Common Bacteria: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis.
• Anatomy: Children have Shorter, More Horizontal Eustachian tubes, predisposing to reflux and obstruction.
• Grommets: The most common operation in children. They bypass the Eustachian tube to ventilate the middle ear.
• Mastoiditis: The main "Red Flag" complication of AOM.

Clinical Pearls

"The Bulging Drum": In AOM, the eardrum (TM) bulges outwards like a donut due to pus under pressure. The landmarks (handle of malleus) are lost. A simply "red" drum is often just crying or viral URT inflammation; a "bulging" drum means AOM.

"It Ruptured!": Parents panic when blood/pus pours out of the ear. This is actually "Nature's Myringotomy". The drum has burst, releasing the pressure. The pain vanishes instantly. It usually heals spontaneously.

"Unilateral Glue Ear in an Adult": In a child, Glue Ear are normal. In an adult, unilateral OME is Nasopharyngeal Carcinoma until proven otherwise. You MUST visualise the post-nasal space (FNE).

"The Pinna Push": If a child's ear sticks out (Proptosis of pinna) and there is a boggy swelling behind it... Run. This is Acute Mastoiditis.

          CHILD WITH ACUTE EAR PAIN
                     ↓
             OTOSCOPY: BULGING?
             FEVER? SYSTEMIC?
                     ↓
      ┌──────────────┼───────────────┐
    MILD/MODERATE   SEVERE / YNG    PERFORATED
    (>2yrs, Well)  (<2yrs, Bilat,  (Discharge)
                     High Fever)
      ↓              ↓               ↓
  ANALGESIA        ANTIBIOTICS     ANTIBIOTICS
 (Wait 48h)       (Amoxicillin)   (Oral or Topical)

1. Analgesia (The Mainstay)

• Paracetamol / Ibuprofen. AOM is painful!
• Most mild cases resolve in 3 days without Abx.

2. Antibiotics

• Indication (NICE NG91):
  • Systemically very unwell.
  • High risk (immunocompromise, CF).
  • Age <2 years with Bilateral AOM.
  • Perforation (Discharge).
• Drug: Amoxicillin 5-7 days. (Clarithromycin if allergy).

1. Active Monitoring ("Watchful Waiting")

• Most OME clears spontaneously in 3 months.
• Re-test hearing at 3 months.

2. Autoinflation (Otovent)

• Child blows up a balloon with their nose. Forces air up Eustachian tube. Moderate evidence.

3. Surgery (Grommets)

• Indication:
  • Persistent bilateral OME >3 months.
  • Hearing level >25-30 dBHL.
  • Speech/Language/Social impact.
• Procedure: Examination Under Anaesthetic (EUA) + Myringotomy + Grommet.

Myringotomy and Ventilation Tube Insertion

1. Microscope: Procedure done under microscopic view (GA).
2. Cleaning: Wax removed.
3. Incision (Myringotomy):
   • Radial incision in the Anterior-Inferior Quadrant.
   • Why? To avoid ossicles (Superior) and round window (Posterior).
4. Aspiration: "Glue" (thick mucus) sucked out.
5. Insertion: Grommet (Bobbin shape) inserted half-in/half-out.
6. Function: It does not "drain" fluid. It Ventilates the middle ear (allows air in), breaking the vacuum so fluid can drain naturally down the ET.
7. Extrusion: The drum heals and pushes the grommet out after 6-12 months.

Adenoidectomy

• Often performed with Grommets ("Adeno-Tonsillectomy").
• Removing the adenoid pad unblocks the Eustachian tube orifice and removes the bacterial reservoir (Biofilm).

NICE NG91 (Bacterial Infections)

• Most otitis media resolves without antibiotics.
• Hold antibiotics for 48 hours ("delayed prescribing") unless high risk criteria met.

TARGET Trial (2000s)

• Confirmed efficacy of Grommets for OME + Hearing Loss, improving hearing by ~12dB in the short term.
• Long term benefit (years) less clear as OME naturally resolves.

What is an Ear Infection (AOM)?

A virus or bacteria gets behind the eardrum. Pus builds up, pushing on the drum like a boil. It hurts a lot and causes a fever. Usually, the body fights it off in 3 days.

What is Glue Ear (OME)?

After a cold, the tube that drains the ear can get blocked. The air in the middle ear gets absorbed and replaced by sticky fluid ("Glue"). It doesn't hurt, but it's like listening underwater. The child can't hear well, which can affect their speech or behaviour.

Do Grommets cure it?

Grommets are tiny plastic tubes we put in the eardrum. They let air in (doing the job of the blocked tube). This dries up the fluid and restores hearing instantly. They usually fall out by themselves after about a year.