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Otitismedia witheffusionEar painwithout earinfectionViral URIBronchiolitisRecurrentacuteotitisConjunctivitisInfluenzaAcuteotitisexternaAcute OtitisMedia

ENT

Acute Otitis Media

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This template hands off to

Otitis media with effusionEar pain without ear infectionViral URIBronchiolitis

Comes up in this visit

Recurrent acute otitis mediaConjunctivitisInfluenzaAcute otitis externa

Template

Acute Otitis Media

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Counseling

Ear pain usually improves over the next few days and may be a little worse the first day. Recommended supportive care with tylenol or motrin as needed for pain. Return precautions given including worsening ear pain, fever that is not improving, swelling or redness behind the ear, drainage from the ear, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

  • AOM with no side specified
  • Right, left, bilateral
  • Moderate to severe TM bulging
  • New otorrhea not due to otitis externa
  • Mild bulging + ear pain < 48 h
  • Mild bulging + intense TM erythema
  • Severe: moderate–severe otalgia, otalgia ≥ 48 h, T ≥ 39 °C, toxic-appearing
  • Recurrent AOM definition (3 in 6 mo, or 4 in 12 mo with 1 in last 6)
  • Antibiotic started (routine)
  • Antibiotics for severe AOM ≥ 6 mo
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  • Antibiotics for bilateral nonsevere AOM < 24 mo
  • Antibiotics for AOM with otorrhea
  • Antibiotics after joint decision-making (3C, 3D)
  • Uncertain access to follow-up treated as severe
  • Observation with close follow-up after joint decision-making
  • Safety-net or wait-and-see prescription
  • Alternative: call or return instead of a written prescription
  • Antibiotics after failed observation
  • Reassess at 48–72 h for worsening or no response
  • Amoxicillin failure: Augmentin
  • Augmentin or oral cephalosporin failure: ceftriaxone 3 d
  • Mild persistent symptoms may not need a change
  • Amoxicillin first-line
  • Ceftriaxone IM or IV, 1–3 days
  • Reason: amoxicillin in past 30 days
  • Reason: concurrent purulent conjunctivitis
  • Reason: recurrent AOM unresponsive to amoxicillin
  • Reason: persistent vomiting or can't take oral medication (ceftriaxone)
  • Assess and treat pain, with or without antibiotics
  • Acetaminophen or ibuprofen
  • Expected course on antibiotics: may worsen slightly in first 24 h, improve next 24 h, fever down by 48–72 h
  • Return or call if worse or not improving in 48–72 h
  • Self-limited nature, especially ≥ 2 y; potential antibiotic side effects
  • Antibiotic side effects: diarrhea, diaper dermatitis
  • Persistent middle ear fluid after AOM is common and doesn't need antibiotics
  • Default follow-up: if worsening or not improving in 48–72 h
  • No routine 10–14 day recheck; reassess young children with severe symptoms or recurrent AOM, or on request
  • Recheck persistent fluid
  • Recheck 2–3 days during observation
  • Recurrent AOM
  • Referred to ENT to discuss tubes
  • ENT for tympanocentesis and culture after repeated treatment failure
  • No prophylactic antibiotics
  • Pneumococcal conjugate vaccine
  • Annual influenza vaccine
  • Exclusive breastfeeding ≥ 6 mo
  • Avoid tobacco smoke exposure
  • Avoid bottle propping; limit pacifier after 6 mo
  • Ceftriaxone given IM in clinic
  • Return daily for ceftriaxone doses 2–3
  • TM perforation with purulent drainage
  • Middle ear effusion on pneumatic otoscopy
  • Penicillin allergy severity: cephalosporin only without severe or recent reaction
  • Observation education (self-limited course) is required with observation

Used to decide, kept out of the note

  • Don't diagnose AOM without MEE
  • Scope exclusions: under 6 mo, tubes, cleft palate, craniofacial syndromes, immune deficiency, cochlear implants
  • TMP-SMX, erythromycin-sulfisoxazole after amoxicillin failure
  • Penicillin cross-reactivity with 2nd/3rd-gen cephalosporins negligible
  • Penicillin allergy definition (IgE-mediated vs not)

Return precautions in the template

worsening ear painfever that is not improvingswelling or redness behind the eardrainage from the ear

Sources