Acute Otitis Media Flowchart

(For children aged 1 to 17 years)
Exclude: recurrent AOM (≥3 episodes in 6 months or ≥4 in 12 months), pregnant individuals under 16.
Acute otitis media mainly affects children, can last for around 1 week and over 80% recover spontaneously without antibiotics.

Consider the risk of deterioration, red flags or serious illness.
Are any acute complications suspected?

Meningitis (neck stiffness, photophobia, mottled skin)
Mastoiditis (pain, swelling, tenderness behind the ear)
Brain abscess (severe headache, confusion, muscle weakness)
Sinus thrombosis (headache behind/around eyes)
Facial nerve paralysis

Gateway Point

Signpost patient to A&E or call 999 in a life threatening emergency.

Does the patient need an otoscopic examination?

Gateway Point

Does the patient have acute onset of symptoms (earache, tugging ear, fever, crying, etc.) AND:

A distinctly red, yellow, or cloudy tympanic membrane
Moderate to severe bulging of the tympanic membrane with loss of landmarks and an air-fluid level behind it
Perforation of the membrane and/or sticky discharge in the canal

Consider alternative diagnosis and proceed appropriately.

Offer self care and regular pain relief to all patients.

Does the patient meet ANY of the following criteria:

Patient is systemically very unwell
Patient has signs of a more serious illness
Patient is high risk of complications because of pre-existing comorbidity (e.g. significant heart/lung/renal disease, immunosuppression, cystic fibrosis, born prematurely)

Onward referral
• General practice
• Other provider

Does the child/young person have otorrhoea (discharge after eardrum perforation) or eardrum perforation (suspected or confirmed)?

Is the child under 2 years AND with infection in both ears?

Shared decision making approach and clinician global impression

Does the patient meet ANY of the following criteria:

Severe symptoms based on clinician global impression
Symptoms for > 3 days

In patients with mild symptoms:
Offer self-care and pain relief.

In patients with moderate/severe symptoms WITHOUT eardrum perforation:
Consider offering phenazone 40 mg/g with lidocaine 10 mg/g ear drops for up to 7 days (subject to PGD) plus self care.

Ask patient to return to Community Pharmacy if no improvement within 3-5 days for pharmacist reassessment.

Offer amoxicillin (if no allergy) for 5 days (subject to PGD criteria) plus self care.

Reported penicillin allergy?

Offer clarithromycin for 5 days plus self care.

If pregnant
(16-17 yrs)

Offer erythromycin for 5 days plus self care.

FOR ALL PATIENTS: If symptoms worsen rapidly or significantly, or the child or young person becomes very unwell OR does not improve despite antibiotics taken for at least 2-3 days -> Onward referral.

FOR ALL PATIENTS: share self-care and safety-netting, and evidence on antibiotics using NICE guidelines.