24 HOW TO TREAT: OTITIS MEDIA IN CHILDREN
24 HOW TO TREAT: OTITIS MEDIA IN CHILDREN
18 JULY 2025 ausdoc. com. au speech – language delays). 1 Management recommendations differ for these children( eg, early audiological and ENT assessments are recommended) to avoid delays causing long-term sequelae. 1, 3
RISK FACTORS
AGE( 0-6 years) is the strongest predictor of OM, followed by having a history of OM. 3, 22-24 Breastfeeding, avoidance of tobacco exposure, good nutrition and healthy( eg, not overcrowded) home environments are recognised as protective factors against OM. Other protective factors include not having a family history of AOM, absence of atopy, season( dry season or summer – autumn) and not using a pacifier( or dummy). 3, 24
Many of these risks are linked to increased exposure to other children. For instance, having siblings or being in out-of-home care raises the risk of AOM, with a dose-dependent effect( more = greater risk). 22-25 Children in daycare centres are at higher risk than those in family day care, and children in family day care are at greater risk than those cared for at home.
Crowded living conditions further increase this risk. Recent observational studies from Australia and New Zealand report associations between household crowding and cross-sectional OM diagnoses and increased OM hospital admissions. 22-26 Genetics also influence the likelihood of recurrent AOM, although there is no strong link to male sex that is often seen in infections. 1
Aboriginal and Torres Strait Islander children
Aboriginal and Torres Strait Islander children experience the highest global rates of OM, with earlier onset and more severe, frequent and prolonged cases compared with other populations. 8 Prevalence varies across communities, with rates ranging between 20 % and 90 %. 27, 28 In the NT and Central Australia, chronic suppurative OM rates( the most severe OM) have fallen from 40 % but are still above 15 %— far exceeding the WHO’ s threshold of 4 % for a major public health concern. 29, 30 The higher rates of OM among Aboriginal and Torres Strait Islander children are largely driven by the disproportionate burden of social determinants, which are deeply rooted in the legacy of ongoing colonisation. 23 Fragmented and inequitable colonial health
Image used with consent.
Figure 1. Positioning the child during an ear examination. Sit them on their parent’ s lap. The parent’ s legs secure the child’ s legs. One arm holds the child’ s chest, and the other supports their head.
and political systems that are not designed by and for Aboriginal people continue to limit equitable access to best practice healthcare for Aboriginal people. 23
Similarly, OM is a widespread health concern among Indigenous children globally, with significant implications for their overall health and wellbeing, highlighting the need for tailored healthcare strategies. This disparity is not limited to Australia; similar health inequities are seen in countries such as the US, Canada and New Zealand, where the effects of colonisation have also harmed Indigenous health and wellbeing. 31-33
The cultural context plays a crucial role when assessing the impact of OM on Indigenous communities. Hearing is deeply connected to cultural practices, language preservation and storytelling traditions, making it vital to consider these aspects when addressing OM. Efforts to manage and reduce its effects must acknowledge the centrality of hearing and communication in maintaining cultural identity and enhancing community wellbeing. 34
SIGNS AND SYMPTOMS
Acute otitis media
AOM is characterised by fluid( usually frank pus) behind the tympanic membrane and acute symptoms. It can be associated with perforation of the tympanic membrane.
The most reliable symptoms are fever and pain or irritability in preverbal children. Vomiting, diarrhoea and balance disruption can also occur. Among Aboriginal and Torres Strait Islander populations in remote settings, symptoms can often be very mild or absent, though the reasons for this are not clear.
The most reliable signs are bulging tympanic membranes or acute discharge. However, it can be difficult to ascertain a small bulge, and the most common findings( opaque or mildly injected tympanic membranes) are not pathognomonic.
The light reflex is also absent or displaced when the tympanic membrane orientation is altered by the presence of fluid, but this is less reliable. Scarring( tympanosclerosis) is indicative of past OM. Wax can make diagnosis difficult, but removal is usually not required in primary care
2-5, 35 as it quickly re-forms.
Otitis media with effusion
OME is characterised by the presence of fluid behind the tympanic membrane without acute symptoms. It is also referred to as‘ glue ear’,‘ serous
Figure 2. Positioning the pinna. Gently pull the pinna backwards and upwards.
Figure 3. Positioning the otoscope. Hold the otoscope like a pen, with the handle resting between your thumb and forefinger. This grip allows you to use your little finger to brace against the child’ s head, preventing the earpiece from being inserted too far. Use your middle and ring fingers to operate the pneumatic insufflator bulb.
otitis media’, or‘ secretory otitis media’. OME may be episodic or persistent( ie, longer than three months) and is often linked to Eustachian tube dysfunction, which causes negative pressure in the middle ear, leading to fluid accumulation. 2-5 Diagnosing OME can be challenging as symptoms may be absent and otoscopic findings misleading. The most reliable diagnostic tools are pneumatic otoscopy( see figures 1-3) and tympanometry
Figure 4. Tympanogram types. Type A. No effusion( peak about 0daPa pressure). Type B. Effusion, shown by a flat trace with no peak. Type C. Possible effusion( peak highly negative range— eg, less than-200daPa), often a precursor to effusion. Only type A and B traces are considered reliable for diagnosis.