EN4.3 | Acute Suppurative Otitis Media — Summary & Reflection

KEY TAKEAWAYS

Acute suppurative otitis media (ASOM) is a staged bacterial infection of the middle ear caused most commonly by Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, arising via Eustachian tube dysfunction following an URTI. It progresses through four stages: Stage 1 (tubal occlusion, retracted TM), Stage 2 (pre-suppuration, hyperaemic TM, loss of cone of light), Stage 3 (suppuration, bulging cherry-red TM, severe otalgia, all landmarks lost), and Stage 4 (resolution after spontaneous perforation or myringotomy, or complication). History-taking establishes the duration, preceding URTI, age-related severity, and red-flag features of spreading infection. Otoscopy demonstrates stage-specific TM changes; tuning fork tests show conductive hearing loss with Rinne negative on the affected side and Weber lateralising to the affected ear. Tympanometry shows Type B curve with effusion. Key differentials are OME (chronic, no fever, amber dull retracted TM), otitis externa (tragal tenderness, normal TM), bullous myringitis (haemorrhagic bullae), and referred otalgia (normal otoscopy). Management is stage-guided: analgesia plus watchful waiting or oral amoxicillin (first-line) for most cases; myringotomy in the anteroinferior quadrant (avoiding ossicles superiorly and jugular bulb posteroinferiorly) for Stage 3 with failed conservative treatment or impending complications. Post-ASOM follow-up at 6–8 weeks detects residual effusion (OME), which may persist and require grommets.

REFLECT

You are the medical officer at a primary health centre. A mother brings her 2-year-old with 4 days of fever (39°C) and bilateral ear tugging. He is irritable and feeding poorly. Otoscopy on the right shows Stage 3 findings (bulging, red TM, landmarks obscured). The left TM looks dull and slightly retracted — Stage 1 picture. You have oral amoxicillin available but no surgical facilities. Reflect: Is watchful waiting appropriate for this child, or do you immediately start antibiotics — and what features drove that decision? At what point and with what clinical triggers would you refer this child for myringotomy? What will you tell the mother to watch for at home that should prompt emergency review? How will you assess whether treatment is working at 72 hours, and what will you do if the child has not improved?