Otitis Referral Guidelines

Diagnosis/Definition

• Otitis media is a general term used to describe an inflammation in the middle ear space without reference to a specific cause.
• Acute otitis media is defined as an episode of inflammation of less than 3 weeks duration.
• Chronic otitis media is defined as inflammation lasting greater than 3 months. Both acute and chronic otitis media can be further characterized as purulent, mucoid, or serous in nature.
• Complications of otitis media include tympanic membrane perforation, hearing loss (with subsequent delay in speech and language development), cholesteatoma (skin growth in the middle ear), mastoiditis, facial nerve paralysis, meningitis, and intracranial and/or neck abscess formation.

Initial Diagnosis and Management

• Signs and symptoms of otitis media:
  ◦ Ear pain, fussiness and poor appetite in children
  ◦ Decreased hearing
  ◦ Otorrhea (drainage from the ear)
  ◦ Fever
  ◦ Middle Ear Effusion – fluid behind the eardrum
  ◦ Damaged eardrum – perforation or retraction pockets
  ◦ Conductive hearing loss
• Ancillary Tests:
  ◦ Tympanometry is a highly reliable test for identifying middle ear effusion/pressure.
  ◦ Audiogram is indicated for patients with a suspected hearing loss.
• Initial Management Of Uncomplicated Acute Otitis Media:
  ◦ For children less than 2 years: A 7-10 day course of a first line antibiotic (e.g., high dose amoxicillin if not allergic)
  ◦ For children over age 2 / adults – observation for up to 72 hours is appropriate with antibiotic therapy reserved those who worsen or show persistent symptoms
  ◦ If the infection resolves, any remaining middle ear fluid (see otitis media with effusion below) can be observed for up to 3 months before obtaining an audiogram and a referral to ENT.
• Initial Management of Uncomplicated Chronic Otitis Media (With Effusion):
  ◦ Initial management of otitis media with effusion should include one course of a first line antibiotic and observation for 3 months.
  ◦ At 3 months an audiogram should be obtained followed by a referral to ENT if the effusion persists or there is significant hearing loss
  ◦ An earlier referral can be considered in patients with known sensorineural hearing loss, cleft palate or another craniofacial syndrome, pre-existing speech delay, or immunodeficiency

Indications for Specialty Care Referral

• Multiple episodes of acute otitis media that produce significant quality of life impairment for the patient and family
  Persistent otitis media with effusion beyond 3 months in an uncomplicated patient
• Otits media with effusion in a complicated patient who is at higher risk for a complication such as cleft palate, Trisomy 21, pre-existing hearing loss, immunodeficiency, etc.
• Otorrhea that does not resolve rapidly with medical therapy
• Concern for complications of otitis media such as tympanic membrane damage, hearing loss, or cholesteatoma