Acute otitis media: the bulge, not the blush

Clinical Rounds, the GPAtlas podcast. ENT. 19 minutes. Published 25 September 2026. Free to listen.

From our Ocean topic Otitis Media (OM) - Acute, reviewed September 2025.

Transcript

Sarah: Hello, and welcome to GPAtlas Clinical Rounds. I'm Sarah, and this is the podcast where we take one thing you'll genuinely see this week and work out what to do with it.

Ben: And I'm Ben. Today it's acute otitis media, after a study this week found only six in ten primary care doctors get the diagnosis right. And our answer is simple: look for the bulge, not the blush.

Sarah: Isla is sixteen months old. Her mum brings her in at the end of afternoon surgery. She's had a cold for three days, then last night a temperature, tugging at her right ear, and nobody slept. Mum says she had antibiotics last time and they cleared it straight up. Isla screams the whole way through the examination, and both drums look red. And most of us, me included on a tired day, would call that a double ear infection and print the amoxicillin.

Ben: Three things today. What actually makes the diagnosis, and why a red drum doesn't. Why regular pain relief is the treatment that matters most. And which children really need an antibiotic, and what you tell everyone else.

Sarah: So, the news first. Six in ten. My honest first reaction was, well, not me. And then I thought about Isla, and how close I came to getting her wrong on a perfectly ordinary Tuesday.

Ben: And let's be fair to the study. It found that only six in ten primary care doctors, across twelve countries, diagnosed acute otitis media correctly. That's the finding. What the headline doesn't settle is which way the mistakes went, or whether it looks the same in a UK surgery. So it's one study, and I wouldn't hang more on it than that.

Sarah: But it rings true. Toddlers wriggle, they scream, and you get a glimpse of the drum if you're lucky. Mum's watching, the clock's running, and the thing you notice in a glimpse is colour.

Ben: And colour is the trap. Our article names the common pitfall: calling every red drum an ear infection. A crying child, a febrile child, any upper respiratory tract infection, can all redden the drum without acute otitis media. And it's blunt about the cost. Redness alone over-diagnoses it, and drives antibiotics nobody needed.

Sarah: One study, one headline. But the trap is real: a red drum is not a diagnosis.

Ben: So what is it? Our article defines it as acute inflammation of the middle ear with an effusion. Fluid behind the drum, plus acute infection. Rapid-onset ear pain, often with fever, irritability and broken sleep. Peak age is six to eighteen months, and most follow a recent upper respiratory tract infection. Viruses and bacteria, often together, and you can't tell them apart clinically.

Sarah: Which is Isla to the letter. She can't tell me it hurts, so I ask mum about ear-tugging and rubbing. Then feeding, fluids, vomiting, how sleepy she is. Any discharge, because that suggests a perforation. And is it one ear or both? Mum says right ear, no discharge, off her milk but still drinking water.

Ben: Then the background, because that's where the risks you can change are hiding. How many episodes in the last six and twelve months? Three or more in six months, or four or more in twelve with at least one in the last six, counts as recurrent. Passive smoke, nursery, bottle-feeding lying flat. And the high-risk groups: Down syndrome, cleft palate, immunocompromise, significant comorbidity.

Sarah: Isla's only other ear infection was in the spring, so she's not recurrent. But she's at nursery four days a week, dad smokes in the house, and she has a bottle lying down at bedtime. So that's a gentle conversation about a smoke-free home and the bedtime bottle, and checking her immunisations. Our article says those reduce recurrence.

Ben: It usually follows a cold. Ask about discharge, one ear or both, and the risks you can change.

Sarah: So I waited for the crying to settle. Mum held her sideways on her lap, cuddled in, and I had another go. Left ear: pink, yes, but I could see the light reflex, and the drum wasn't pushed out. Right ear: completely different. Full, bulging, cloudy, and no light reflex at all.

Ben: And that's the sign our article hangs everything on. A bulging drum with loss of the light reflex. The drum may also be red, or cloudy, or show an air-fluid level. But the diagnostic combination is a bulging or full drum plus acute symptoms. Not the colour. The bulge.

Sarah: So the left ear was the blush. She'd been screaming, she had a fever, she had a cold. Any one of those can redden a drum. The right ear was the bulge. One ear, not two. And that difference matters later, more than you'd think.

Ben: And if you genuinely can't tell, our article is clear: don't treat the colour. Confirm there's fluid behind the drum with pneumatic otoscopy or tympanometry. That also helps separate it from glue ear. Otherwise there are no routine tests. It's a clinical diagnosis, made on the history and the otoscopy.

Ben: Bulging, with no light reflex, plus acute symptoms. That's the diagnosis. Red on its own isn't.

Sarah: Which brings me to the two mimics I try to rule out before I commit. Glue ear, and otitis externa. Because not every sore or blocked ear in a toddler is acute otitis media, however red it looks.

Ben: Our article puts them side by side. Otitis media with effusion, so glue ear, is painless. A dull or retracted drum, maybe a fluid level, and the main problem is reduced hearing. No acute infection. Otitis externa, the swimmer's ear, hurts when you move the tragus or the pinna. The canal's red, swollen and weepy, and the drum's often normal.

Sarah: And they're treated completely differently. Glue ear is watchful waiting, audiometry, and grommets if it persists. Otitis externa is aural toilet and topical drops, and keeping the ear dry. With Isla I moved the pinna gently, and she minded it no more than everything else I'd done to her.

Ben: Glue ear is painless, with poor hearing. Otitis externa hurts when you move the ear.

Ben: Then the bit that happens every time, even when it's clearly a simple ear. Look behind it. Our article's first red flag is mastoiditis: tender, boggy swelling behind the ear, loss of the crease behind it, and a pinna that sticks out. That's emergency admission for intravenous antibiotics.

Sarah: Then the rest of the list. Neck stiffness, photophobia, a non-blanching rash. Facial weakness. New vertigo. And the whole child: temperature, hydration, alertness, capillary refill, breathing rate. Toxic, drowsy or shocked, I'm asking could this be sepsis, and she goes in. Isla was hot, but alert, wet nappies, quick refill.

Ben: And each of those has a destination. Signs of meningitis, an intracranial abscess or sinus thrombosis: nine nine nine or emergency admission. Facial nerve palsy or new vertigo: emergency assessment by ear, nose and throat, so ENT. Our article says check the cranial nerves and balance if you suspect a complication, but don't let that delay the referral.

Sarah: And the tiny ones have their own thresholds. Under three months with a temperature of thirty-eight or more is high risk, so urgent paediatric assessment. Three to six months with thirty-nine or more is at least intermediate risk, so urgent face-to-face assessment.

Ben: Look behind the ear every time. Then ask whether this is a sick child, not just a sore ear.

Sarah: So back to Isla's mum, who still wants the antibiotics. I've learnt to ask before I explain. What worries you most? The pain, she says, and the nights. Nobody's slept, she's missed two days of work, and last time the antibiotics seemed to fix it overnight.

Ben: Which is exactly what our article asks you to explore. The worry about pain and fever, what she's expecting, what happened last time, and what it's doing to the family. Then the natural history, because it's reassuring. It's self-limiting. About three days, occasionally up to a week. Most children are better within three days without antibiotics.

Sarah: And then the line that does the most work for me. Antibiotics make little difference to the pain at twenty-four hours. And they don't prevent the rare complications, like mastoiditis. So if the nights are the problem, the antibiotic isn't the answer. Last time, she'd probably have got better anyway.

Ben: Pain relief is. Our article calls it the mainstay of care. Regular paracetamol or ibuprofen, at age or weight-appropriate doses, using the maximum doses for severe pain. Regular, not just when she seems bad. It puts the number needed to treat for no pain at forty-eight hours at around six to seven.

Sarah: Most are better in three days. Regular painkillers are the treatment. Antibiotics make little difference to the pain.

Ben: Two cautions with ibuprofen, though. It's a non-steroidal anti-inflammatory drug, an NSAID, and our article says avoid or limit it in a dehydrated or significantly unwell child. Acute kidney injury risk. And in NSAID-sensitive asthma.

Sarah: Isla was drinking, so ibuprofen was fine. I also suggested a warm flannel held against the ear, plenty of fluids and rest. Then mum pulled a bottle of cold medicine out of her bag and asked if she should keep going with it.

Ben: And our article says no. Decongestants and antihistamines don't help, so don't recommend them. There is an anaesthetic eardrop, phenazone with lidocaine. Four drops two to three times a day, for up to seven days. But only if there's no immediate oral antibiotic, and no perforation or discharge. And review if she's no better within seven days.

Sarah: Check she's drinking before ibuprofen. No decongestants or antihistamines. Eardrops only with an intact drum and no discharge.

Sarah: So, antibiotics. And this is where the blush really costs you. If I'd called that left ear, Isla's suddenly under two with acute otitis media in both ears. That's a different conversation.

Ben: It is. Our article has three tiers. Most children get no antibiotic, or a back-up prescription to use if symptoms don't start to improve within three days, or worsen at any time. Then the group more likely to benefit: discharge from the ear at any age, or a child under two with bilateral disease. There you consider none, a back-up, or an immediate antibiotic.

Sarah: And the immediate antibiotic is for the child who's systemically very unwell, has signs of something more serious, or is at high risk of complications. Isla was none of that. One ear, alert, drinking. So she got a back-up prescription, to use only if she isn't starting to improve by day three, or gets worse.

Ben: High risk, in our article, means significant immunodeficiency, or cardiac, respiratory, renal or neuromuscular disease. And make the safety-net specific. Come back if discharge appears, the pain becomes severe, there's swelling behind the ear, drowsiness or repeated vomiting, or no improvement by three days.

Sarah: Get the ears right, because under two and bilateral changes the decision. Most children: no antibiotic, or a back-up.

Ben: If mum does use it, it's amoxicillin for five to seven days. Our article gives the doses. One to eleven months: one hundred and twenty-five milligrams three times a day. One to four years: two hundred and fifty milligrams. Five to seventeen years: five hundred milligrams. All three times a day.

Sarah: So two hundred and fifty for Isla. And two questions before I sign it. Is this a true penicillin allergy, or a rash she once had? And could this be glandular fever? Because amoxicillin causes a widespread rash in glandular fever, so you avoid it if you suspect that.

Ben: For a genuine allergy, it's clarithromycin, weight-banded twice daily from one month to eleven years, for five to seven days. Mind the macrolide warning: QT prolongation and interactions, so no simvastatin alongside it. And if a child is worsening after at least two to three days on the first choice, the second choice is co-amoxiclav.

Sarah: Amoxicillin first, dosed by age. Check the allergy is real. Co-amoxiclav only if they're worsening on it.

Sarah: Here's how it ended. Mum rang on day two. Isla had woken with yellow gunk on the pillow, and she was suddenly cheerful, playing, eating. Mum was frightened. Her eardrum's burst, hasn't it? Is she going to be deaf?

Ben: And our article's clinical pearl is written for that call. A sudden gush of discharge that relieves the pain usually means the drum has perforated. It's not a disaster. Most perforations heal on their own. Keep the ear dry, no cotton buds, and no flying while it's acutely infected.

Sarah: It changed two things for me, though. Discharge at any age is the more-likely-to-benefit group, so we talked again about using that back-up script. And the anaesthetic drops are off the table now. If she ever needs drops, they're non-ototoxic, and no aminoglycoside drops where there's an alternative.

Ben: Then the follow-up everyone forgets. Recheck the drum at six to eight weeks. Perforation or discharge persisting beyond that needs ENT review. And ask about her hearing, because glue ear is the commonest after-effect. If hearing's still reduced once the episode settles, that's a routine referral for audiometry and tympanometry.

Sarah: A gush, and the pain goes: usually a perforation, not a disaster. Keep it dry, and recheck at six to eight weeks.

Ben: Right, exam corner. A twenty-eight-year-old woman, twenty weeks pregnant, has acute otitis media with a bulging drum, and you've decided she needs an immediate antibiotic. She has a true penicillin allergy, with a rash and lip swelling last time. Which antibiotic? A, amoxicillin. B, clarithromycin. C, erythromycin. D, co-amoxiclav.

Ben: C, erythromycin. Our article says that in pregnancy, erythromycin is the preferred macrolide, in line with the advice on macrolides in pregnancy. Two hundred and fifty to five hundred milligrams four times daily, or five hundred milligrams to one gram twice daily, for five to seven days. B is the tempting one. Clarithromycin is the penicillin- allergy choice, but only when she isn't pregnant. A and D are both penicillins.

Sarah: So. Three things for Monday. One. Look for the bulge, not the blush: a bulging drum with no light reflex, plus acute symptoms. Red on its own isn't the diagnosis. Two. Regular paracetamol or ibuprofen for everyone, and no antibiotic or a back-up for most. And three. Look behind the ear every time, and give a clear three-day safety-net.

Sarah: One thing to reflect on, if you're logging this. Think of the last child you diagnosed with an ear infection. Can you remember whether the drum was bulging, or only that it was red? Check your local guidance before you act on it. The full transcript and the sources are on the episode page. Ben and I are natural AI voices, and what we've said comes from our reviewed Ocean topic. Check your local guidance before you act on it. See you next week.

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