Acute otitis media (H71)

March 3, 2023
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 the accumulation of secretions. Colonising bacteria and viruses can lead 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 young children, especially those under one year old, AOM may present aspecifically, 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.

The diagnosis can be made if there is acute ear pain and / or illness (e.g. fever) in combination with (1) a red, bulging, and / or opaque tympanic membrane, or (2) a marked leftright difference in redness of the tympanic membrane, or (3) briefly existing otorrhoea.

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 a higher risk of complications, such as those under six months old, 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 H71. The symptom diagnoses ‘ear ache / pain in the ear’ (H01) and ‘otorrhea’ (H04) may be recorded when these 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 AOM is present and requiring treatment, GPs will likely classify it as AOM (H71). This is a clinical assessment.

Epidemiology of acute otitis media in FaMe-Net

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

Prevalence of AOM is 18.8 per 1000 patient years, which means that among 1000 patients, 19 individual patients seek help from their GP for AOM every year. The comparability of the prevalence and incidence numbers suits the short episodic nature of the condition AOM. The slightly higher number for incidence (new diagnoses) compared with the number for prevalence (affected persons) shows that AOM is a condition that can recur in the same person within a calendar year.

Like the incidence, the prevalence is highest in the 0-4 age group, followed by the 5-14 group. Link/Figure 3 In the age group 0-4, incidence and prevalence are slightly higher for boys compared to girls.

The incidence and prevalence of AOM has decreased since 2019. This shows the effect of the COVID-19 pandemic that started in 2020, where the number of cases of AOM dropped dramatically as a result of missed presentation to the GP and decreased upper airway infection pressure as a result of the covid measures (Schers et al., 2021). The decline in the trend graph starts in 2019 by calculating the ‘rolling three years average’, resulting in a smoothened curve that indicates the direction of changes over time without emphasising occasional outliers.

Which initial RFEs do patients with acute otitis media present to their GP?

The most common initial reasons for encounter (RFEs) for acute otitis media are pain in the ear (H01) and fever (A03), in 34% and 24% of all episodes, 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 state to believe the diagnosis is AOM right when the consultation first begins. Link/Table 4 Fever (A03) as an RFE decreases in patients with AOM as age increases age, while the percentage with ‘self-suspected AOM’ as an RFE (H71) increases with increasing age. Link/Table 5

How do FaMe-Net GPs act?

After performing a physical examination (otoscopy), the most common GP intervention is the prescription of medication, occurring in 63% of all episodes Link/Table 6 The main group of prescribed drugs is penicillin with an extended spectrum (J01CA, e.g. amoxicillin), in 41%. This is followed by locally administered medication (ear drops) combining corticosteroids and anti-infectives (S02CA), in 11% of episodes and by NSAIDs (M01AE, 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 Among older patients with AOM (aged 45-74), the percentage that is referred to secondary care increases (to 13% of all episodes) compared with 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


Dutch guideline: (2014)

Wald ER. Acute otitis media in children: Clinical manifestations and diagnosis. In: UpToDate, Edwards MS, Isaacson GC, Blake D (Eds), UpToDate, Waltham, MA, 2023

Pelton IS, Tähtinen P. Acute otitis media in children: Treatment. In: UpToDate, Edwards MS, Isaacson GC, Blake D (Eds), UpToDate, Waltham, MA, 2023

Lim CJ, Lustig LR, Durand ML. Acute otitis media in adults. In: UpToDate, Deschler DG, Givens J (Eds), UpToDate, Waltham, MA, 2023

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