Professor Hasantha
Gunasekera( left) Professor of paediatric priority populations and general paediatrician, Children’ s Hospital Westmead Clinical School, University of Sydney, NSW.
Dr Jack DeLacy( PhD)( right) Public health audiologist, lecturer and research fellow, Poche Centre for Indigenous Health and School of Medicine, University of Sydney, NSW.
Copyright © 2025 Australian Doctor All rights reserved. No part of this publication may be reproduced, distributed or transmitted in any form or by any means without the prior written permission of the publisher. For permission requests, email: howtotreat @ adg. com. au
This information was correct at the time of publication: 18 July 2025
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BACKGROUND
OTITIS media refers to all forms of
inflammation of the middle ear— usually occurring secondary to bacterial and / or viral infection. 1-4 Active inflammation is typically associated with middle ear effusion, which can be serous fluid or pus.
Otitis media( OM) is the most common diagnosis in preschool-aged children and is one of the most common reasons for outpatient antibiotic prescribing globally. 3, 4 OM peaks at approximately two years of age and is the most common reason for hearing loss among children, which is usually mild and transient. 1 However, recurrent OM and chronic / persistent OM can lead to permanent hearing loss. 5 The most common types of OM in primary healthcare are acute OM( AOM), with / without perforation, and OM with effusion( OME). 6
OM has affected children across the globe throughout history. The 3000-year-old Egyptian Ebers Papyrus suggested a remedy of goat’ s urine and bat wings for suppurative OM. 7 Ancient Greek and Roman physicians attributed OM to humours and pioneered tympanostomies and
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ear toilet by cutting the eardrum and using vinegar washes. Indian swamis recommended drinking butter and keeping silent to address draining ears.
Indigenous children have long been at high risk of OM. CT scans of Inuit skulls have shown signs of chronic ear disease and letters from 18th century Australian settlers noted ear discharge among Aboriginal and Torres Strait Islander children.
Aboriginal and Torres Strait Islander children continue to experience the earliest onset, highest prevalence, highest recurrence rates and highest complication rates of children globally. 8 This is especially concerning because of the cultural importance of oral traditions and storytelling within these communities, practices passed down for tens of thousands of years. 9, 10
This How to Treat covers the diagnosis, management and prevention of OM and aims to equip GPs with practical strategies to optimise care and improve outcomes for children, including those from priority populations, particularly Aboriginal and Torres Strait Islander children.
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BURDEN OF DISEASE
OM is a common cause of illness in
young children, especially infants. Annually, more than 700 million people are affected by OM, with most being children under five. 11 Nearly all children will have OM before starting school. The highest risk is among infants between six months and two years. 1 However, Aboriginal and Torres Strait Islander children can develop OM just days or weeks after birth. 12
OM is a common diagnosis in primary care globally. Given it tends to be managed with antibiotic prescriptions, often contrary to guideline recommendations, it is a major driver of antibiotic resistance. 13 Treatment of OM in the US costs an estimated $ US 5 billion per annum. 14 In Australia, some estimates put the cost( including time off work for the parents / carers) at $ 1 billion per annum. 15
Australian OM mortality data show nine deaths in 2022 from the sequelae of OM— for example, meningitis, mastoiditis and brain abscesses. Globally, this figure is approximately 21,000 deaths annually, so it is not a major cause of mortality. 16 However, OM causes significant morbidity, particularly hearing impairment. Other
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symptoms include pain, irritability, fever and vomiting in the acute phase and balance and behavioural disturbances in the chronic phase. 3, 5
Hearing impairment from chronic / recurrent OM may also delay speech and language development— often at critical times for the development of auditory processing pathways. 17-20 Fortunately, OM and conductive hearing loss are short-lived in most children and no intervention is required. However, if prolonged or associated with complications, such as a persistent perforation of the tympanic membrane, sounds are not perceived correctly, fewer neural pathways are established and long-term adverse impacts can result. 21
In these‘ otitis prone’ children, medical interventions( such as antibiotics and autoinflation) and surgical interventions( ventilation tubes and myringoplasties) are considered. 3 Priority populations in whom to consider more aggressive OM management rather than observation include Aboriginal and Torres Strait Islander children; those with midface abnormalities, cleft palates, immune disorders; and children with developmental delays( particularly
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