HFHT's Choosing Wisely Newsletter
For the whole healthcare team.
Issue 65: Otitis Media
As we head into another season of viruses, it is important to remember good antibiotics stewardship. Mathematical modelling has shown that by the year 2050, if we continue as we are now, more people will die world-wide from antibiotic-resistant infections than cancer.
In continuing with our current theme, we will explore otitis media next.

3-year-old girl brought by her parents for the following:
  • Ear ache right side x 24 hours
  • Feverish
  • Eating less but drinking well
  • Coughing and runny nose +++
  • Did not sleep the last night

Parents are tired. They want relief.


  • Hugging her mother
  • Irritable but calm when not approached
  • Tympanic temperature = 38.4
  • Erythematous tympanic membrane; not bulging
  • Obvious nasal discharge
  • No lymphadenopathy
  • Normal oropharynx normal
  • Respiratory exam normal

What should you do?

a) Oral amoxicillin now.
b) Viral prescription.
c) Delayed amoxicillin prescription.

Uncomplicated Otitis Media:

  • Most cases are viral.

You should consider antibiotics in vaccinated children > 6 months and adults ONLY in the following circumstances:

  • The tympanic membrane is suspected to be perforated and there is a purulent discharge.
  • The tympanic membrane is red and bulging WITH one of the three following criteria;

  1. A fever is present (≥ 39ºC) OR,
  2. The patient is moderately or severely ill OR,
  3. Symptoms lasting > 48 hours.
Back to our case...

What can help the patient immediately is the

  • Ibuprofen 10mg/kg every 6 hours +/-
  • Acetaminophen 15mg/kg every 4 hours

If combining the above pain killers, they can be given together at every 6 hours for convenience.

There is a study that shows the combination works better for pain than one alone and can be used for a short course safely.
The Viral Prescription and the Delayed Prescription are downloadable in custom format for Telus, Oscar and Accuro directly from Choosing Wisely Canada .  
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