Clinical course of acute otitis media

Acute otitis media (AOM) is an infection of the middle ear. It is also known as purulent otitis media or suppurative otitis media. It is a common disease in children.  

A viral upper airway infection, leading to oedema in the mucosa of the nose, nasopharynx and Eustachian tube, usually precedes AOM. Obstruction causes poor ventilation of the middle ear with accumulation of secretions. Colonising bacteria and viruses can progress to suppuration. A building pressure in the middle ear causes pain, hearing loss, and may eventually cause the tympanic membrane to rupture, resulting in otorrhea. The most common bacterial pathogens causing AOM are Streptococcus pneumoniae and Haemophilus influenzae. In the large majority of cases, acute signs and symptoms resolve without active treatment within three days. Complications such as mastoiditis and facial nerve palsy occur seldomly. 

In younger children AOM may present nonspecific, with fever, general irritability, or disturbed sleep and feeding. AOM is often accompanied with symptoms of an upper airway infection. Acute otorrhoea in children with tympanic tubes is also considered an AOM. 

Physical examination includes otoscopy showing a bulging and/or erythematous tympanic membrane. Fluid in the middle ear results in an opaque tympanic membrane. A perforation or purulent material may be visible in a membrane rupture.  

Because of the generally favourable course of AOM, treatment in the Netherlands is focused on symptom relief with analgesics. Antibiotics are advised only for severely ill children, and for children at higher risk for complications, such as age under six months, immunocompromised children and children with craniofacial anatomic abnormalities.

How is acute otitis media recorded in FaMe-Net?

In ICPC-2, acute otitis media is coded with H71. The symptom diagnoses ear ache/pain in the ear (H01) and otorrhea (H04) may be recorded when symptoms are present but the diagnosis AOM cannot be made. Upper respiratory tract infection (R74) may show some overlap with AOM and will be recorded if the clinical picture fits best to that diagnosis. If along with a (mild) upper respiratory infection an evident OMA is present requiring treatment, GPs will likely classify it as OMA (H71). This is a clinical assessment.

Epidemiology of acute otitis media in FaMe-Net

The incidence of acute otitis media is 19.6 per 1000 patient years; highest in the age group 0-4 years old, with more than 150 new diagnoses per 1000 patient years, followed by the group 5-14 years with 30 new diagnoses per 1000 patient years. Link/Figure 1 AOM is less common in older patients, but among the youngest children (ages 0-4) it is in the second place of frequently made diagnoses, following acute upper respiratory infection (R74). Link/Table 2

Prevalence of AOM is 18.8 per 1000 patient years, which means that among 1000 patients, 19 patients seek help from their GP for AOM every year. In the age group 0-4, the prevalence is highest, followed by the age group 5-14. Link/Figure 3 In the age group 0-4, both incidence and prevalence are slightly higher for boys compared to girls. 

Incidence and prevalence of AOM declined after 2018. This shows the effect of the covid pandemic that started in 2020, where the number of cases of AOM dropped dramatically. The trend graph shows a smoothened ‘rolling three years average’ pointing at the direction of changes over time without emphasising occasional outliers. See the Background for more information.

How do patients with acute otitis media present to their GP?

The most common initial reasons for encounter (RFEs) for acute otitis media are ‘ear ache/pain in the ear’ (H01) and ‘fever’ (A03), in 34% and 24% respectively. Another frequently recorded RFE is ‘ear discharge’ (H04). ‘AOM’ (H71) itself is the RFE in 5% of all new episodes of AOM, meaning that some patients or parents already when the consultation starts state to believe that the diagnosis is AOM. Link/Table 4 ‘Fever’ as RFE decreases in importance in patients with AOM of increasing age, while the percentage with ‘self-suspected AOM’ as RFE (H71) increases with increasing age. Link/Table 5

How do FaMe-Net GPs act

After performing physical examination (otoscopy), the most common GP intervention is prescription of medication, occurring in 63% of episodes. Link/Table 6 The main group of prescribed drugs is penicillin with extended spectrum (e.g. amoxicillin) in 42%. They are followed by locally administered medication (ear drops) combining corticosteroids and anti-infectives in 11% of episodes, and by NSAIDs (e.g. ibuprofen) in 2%. Link/Table 7 A referral to a medical specialist is recorded in only 6% of the episodes of AOM per year. This concerns referrals to otorhinolaryngology or to paediatrics. Link/Table 8 In older patients with AOM, the percentage that is referred to secondary care increases compared to the younger patients. Link/Table 9 The rate of prescribed antibiotics is lower among adults over 25 years with AOM (33% penicillin with extended spectrum). Link/Table 10 

Reference list:

Schers, Van Weel, Van Boven, Akkermans, Bischoff, Olde Hartman. The COVID-19 Pandemic in Nijmegen, the Netherlands: Changes in Presented Health Problems and Demand for Primary Care. 

Ann Fam Med. 2021 Jan-Feb; 19(1): 44–47. doi: 10.1370/afm.2625

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