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ent.otitis-media.core.v1

Acute otitis media (ENT/EM lens)

general_internal_medicineacutesubacuteadultpediatricacuteoutpatientinpatient
Start encounter →Print handoutPRODUCTION

ENT/EM-framed acute otitis media engine — lifespan, pediatric-predominant. Owns the two managed AOM decisions (observation-vs-immediate-antibiotic per AAP 2013 age/severity/laterality/otorrhoea criteria; high-dose amoxicillin → amox-clav → penicillin-allergy/parenteral ladder with mandatory parallel analgesia). OME (effusion without acute inflammation) and otitis externa (canal disease) are explicitly out of the antibiotic frame; suppurative complications (mastoiditis, otogenic facial palsy, suppurative labyrinthitis, intracranial extension, sepsis) are recognised then routed OUT by engine_id (ent.otitis-externa.core.v1, id.bacterial-meningitis.core.v1, id.sepsis.core.v1) — not re-authored here. Guidelines reconciled live 2026-05-17: AAP 2013 (Lieberthal, PMID 23439909) remains the current US AOM authority — no 2024-2026 AAP replacement (WebSearch-verified). NICE NG91 current (2018, updated 2022, Nov-2025 sepsis-link refresh). AAO-HNS tube guideline is the 2022 update (Rosenfeld, PMID 35138954). Cochrane AOM-antibiotics is the 2023 refresh (Venekamp, PMID 37965923) used for effect sizes; the 2013 Cochrane is retained only as the <2 y bilateral/otorrhoea individual-patient-data anchor. 2024 Italian intersociety consensus cross-checked as concordant. RxCUIs used as provided in the authoring brief (amoxicillin 723, amoxicillin-clavulanate 19711, azithromycin 18631, cefdinir 25033, ceftriaxone 2193, ibuprofen 5640, acetaminophen 161). These were NOT independently re-validated against live RxNav this session — flagged for the orchestrator/next-session RxNav verification before any PRODUCTION promotion; INTEGRATED does not hard-require rxcui and no codes were fabricated (any uncertain code was left to a non_pharm decision-gate/topical entry instead). Bayesian linkage (pre-test AOM/OME/OE/referred-otalgia priors by age/season; LR+/LR− for the key otoscopic findings — bulging TM adjusted LR+ 51, cloudy 34, distinctly immobile 31, distinctly red 8.4, normal colour LR− 0.2, ear pain LR+ 3.0-7.3, all Rothman JAMA 2003 PMID 14506123; conditional dependence of pneumatic-otoscopy mobility + tympanometry; observe-vs-treat decision thresholds; cross-engine routing edges by engine_id) is documented in the co-located _design-brief.md + _research-bundle.md; first-class TS LR fields remain schema-blocked (same constraint as derm.cellulitis.core.v1). Effect sizes embedded (≥5 distinct): spontaneous improvement ~80% by 2-3 d and antibiotic NNTB 20 for pain at 2-3 d with NNH 14 for adverse events (Venekamp Cochrane 2023, PMID 37965923); Tähtinen NEJM 2011 treatment failure 44.9% placebo vs 18.6% amox-clav, HR 0.38 (95% CI 0.25-0.59), rescue-treatment HR 0.19 (PMID 21226577); Hoberman NEJM 2011 clinical failure 16% amox-clav vs 51% placebo at day 10-12 (PMID 21226576); Hoberman NEJM 2016 5-day vs 10-day clinical failure 34% vs 16% in <2 y (PMID 28002709); bulging-TM adjusted LR+ 51 / cloudy 34 / immobile 31 / normal-colour LR− 0.2 (Rothman JAMA 2003, PMID 14506123); acute mastoiditis ~5.6/10 000 and otogenic brain abscess ~0.03/10 000 AOM episodes, antibiotic-for-AOM OR 0.54 for mastoiditis with NNT ~2181 (Cushen BJGP 2020, PMID 32152042); grommets vs active monitoring NNT ~3 (no AOM at 6 mo) (Venekamp Cochrane 2018, PMID 29741289). Cross-reference engine_ids (strings, not imported): ent.otitis-externa.core.v1 (canal-disease mimic, topical-only), id.bacterial-meningitis.core.v1 (intracranial extension), id.sepsis.core.v1 (sepsis from a suppurative complication).

Entry points (5)

  • symptom
    Acute ear pain (ear-tugging/irritability in a preverbal child) often after/with a viral URI — the commonest AOM presentation (AAP 2013 Lieberthal; Rothman JAMA 2003 — ear pain LR+ 3.0-7.3)
    acute_otalgia_with_febrile_url_child
  • symptom
    New acute purulent otorrhoea through a perforated TM (NOT a swimmer / canal-traction-tender ear) — AOM with perforation; one AAP 2013 diagnostic pathway by itself
    new_acute_otorrhoea_not_swimmer
  • symptom
    Bulging / cloudy / distinctly immobile TM on (pneumatic) otoscopy — the strongest objective AOM finding (Rothman JAMA 2003 — bulging adjusted LR+ 51, cloudy 34, immobile 31)
    bulging_or_cloudy_tm_on_otoscopy
  • history
    Recurrent AOM (≥3 episodes/6 mo or ≥4/12 mo with ≥1 in the prior 6 mo) — tympanostomy-tube referral entry (AAO-HNS Rosenfeld 2022; AAP 2013)
    recurrent_aom_3in6_or_4in12
  • symptom
    AOM PLUS post-auricular swelling/protruding pinna, facial droop, vertigo/nystagmus, meningism, or toxic appearance — suppurative-complication entry (recognise → route OUT) (AAP 2013; Cushen BJGP 2020)
    aom_with_complication_red_flag

Required inputs (17)

  • tm_appearancerequired
    symptom • used at INITIAL_WORKUP
    Bulging/cloudy/immobile TM is the single strongest AOM sign and the AOM-vs-OME pivot; the AAP 2013 stringent definition requires moderate/severe bulge OR new otorrhoea (Rothman JAMA 2003 — bulging adjusted LR+ 51; AAP 2013 Lieberthal)
  • middle_ear_effusion_presentrequired
    symptom • used at INITIAL_WORKUP
    MEE (impaired pneumatic-otoscopy mobility, air-fluid level, type-B tympanogram) is necessary for AOM AND for OME; its presence with vs without acute inflammation is the AOM/OME discriminator (AAP 2013 Lieberthal; Rothman JAMA 2003 — immobile TM LR+ 31)
  • acute_inflammation_signsrequired
    symptom • used at CONTEXT
    Marked TM erythema and/or otalgia/distinct ear-tugging defines the "acute inflammation" half of AOM; effusion WITHOUT these is OME (not an antibiotic disease) (AAP 2013 Lieberthal; Rothman JAMA 2003 — distinctly red TM LR+ 8.4, normal colour LR− 0.2)
  • laterality_uni_vs_bilateralrequired
    symptom • used at CONTEXT
    Bilateral AOM (esp. <2 y) shifts the observation-vs-antibiotic decision toward immediate antibiotics and confers the largest treatment benefit (AAP 2013; Hoberman NEJM 2011; Venekamp Cochrane 2023 — antibiotics most beneficial <2 y bilateral)
  • otorrhoea_presentrequired
    symptom • used at CONTEXT
    Otorrhoea (through perforation, no tube) marks more severe AOM with the largest absolute antibiotic benefit and removes the observation option (AAP 2013; Venekamp Cochrane 2023 — AOM+otorrhoea high-benefit subgroup)
  • age_monthsrequired
    demographic • used at ENTRY
    Age is the master switch of the AAP 2013 algorithm: <6 mo always antibiotic; 6-23 mo bilateral / any severe → antibiotic; ≥2 y nonsevere unilateral → observation option (AAP 2013 Lieberthal)
  • severe_aom_criteriarequired
    symptom • used at RISK_STRATIFICATION
    Severe AOM (moderate/severe otalgia, otalgia ≥48 h, or temperature ≥39 °C) mandates immediate antibiotics at any age — removes the observation option (AAP 2013 Lieberthal)
  • mastoiditis_signsrequired
    symptom • used at RED_FLAGS
    Post-auricular erythema/tenderness/fluctuance, protruding auricle, loss of post-auricular crease → acute mastoiditis; recognise and route OUT for ENT/drainage (AAP 2013; Cushen BJGP 2020 — incidence ~5.6/10 000 AOM)
  • intracranial_or_neuro_red_flagsrequired
    symptom • used at RED_FLAGS
    Meningism, altered consciousness, focal deficit, seizures, facial palsy, or vertigo/SNHL → intracranial extension / facial-nerve / labyrinthine complication; route OUT (AAP 2013; Cushen BJGP 2020 — brain abscess ~0.03/10 000)
  • antibiotic_in_prior_30_daysrequired
    history • used at TREATMENT
    Amoxicillin within 30 days (or concurrent purulent conjunctivitis) selects amoxicillin-clavulanate over plain amoxicillin for β-lactamase coverage (AAP 2013 Lieberthal — conjunctivitis-otitis syndrome ≈ H. influenzae)
  • penicillin_allergyrequired
    history • used at TREATMENT
    Penicillin allergy gates the entire β-lactam ladder to cefdinir/cefuroxime/cefpodoxime (non-severe) or azithromycin/clindamycin or ceftriaxone (severe) (AAP 2013 Lieberthal)
  • tympanostomy_tube_or_perforation_in_situ
    history • used at TREATMENT
    Tube/perforation in situ converts management to TOPICAL ototopical antibiotic drops only (no oral) for uncomplicated otorrhoea (AAO-HNS Rosenfeld 2022 KAS14)
  • weight_kgrequired
    demographic • used at TREATMENT
    Weight-based dosing — high-dose amoxicillin 80-90 mg/kg/day divided BID is weight-driven (AAP 2013 Lieberthal)
  • temperaturerequired
    vital • used at CONTEXT
    Temperature ≥39 °C is a severe-AOM criterion and feeds the toxic-child / pediatric-fever screen (AAP 2013; workup.pediatric_fever)
  • craniofacial_anomaly_or_immunocompromise
    history • used at CONTEXT
    Cleft palate / craniofacial anomaly / Down syndrome / immunocompromise / cochlear implant lowers the observation threshold and the ENT-referral threshold (AAP 2013 Lieberthal — excluded from the observation option)
  • recurrent_aom_3in6_or_4in12
    history • used at FOLLOWUP
    Recurrent AOM (≥3 episodes/6 mo or ≥4/12 mo with ≥1 in the prior 6 mo) with a middle-ear effusion present is the tympanostomy-tube referral trigger and the FOLLOWUP recurrence-prevention input (AAO-HNS Rosenfeld 2022; Venekamp Cochrane 2018 — tubes vs active monitoring NNT ~3 at 6 mo)
  • pregnancy_or_lactation
    history • used at TREATMENT
    Adult/adolescent AOM antibiotic-safety gating — amoxicillin/amox-clav are pregnancy-safe; avoid doxycycline; azithromycin acceptable in true penicillin allergy (AAP 2013; standard antimicrobial pregnancy safety)

12-phase flow (12)

  1. 1FRAME
    Frame AOM as middle-ear effusion PLUS acute inflammation, lifespan but pediatric-predominant. The two managed decisions are (1) observation vs immediate antibiotic and (2) the antibiotic ladder + mandatory analgesia. OME (effusion without inflammation — not an antibiotic disease) and otitis externa (canal disease — topical, routed OUT) are explicitly out of the antibiotic frame. Suppurative complications (mastoiditis, facial palsy, labyrinthitis, intracranial extension, sepsis) are recognised and routed OUT by engine_id, not re-managed here.
    advance: AOM antibiotic frame confirmed; OME/OE and complication-routing scope set
  2. 2ENTRY
    Recognise the entry: acute otalgia/ear-tugging with a febrile URI, new non-swimmer otorrhoea, a bulging/cloudy TM on otoscopy, the recurrent-AOM tube-referral entry, or AOM with a complication red flag. Capture age up front — it is the master switch of the AAP 2013 decision algorithm.
    inputs: age_months
    advance: entry trigger present; age recorded
  3. 3CONTEXT
    Build the AOM context and prior: acute-inflammation signs (otalgia/erythema), laterality (bilateral vs unilateral), otorrhoea, temperature, recurrent-AOM history, and the special-population modifiers (craniofacial anomaly/cleft palate, immunocompromise, tube in situ, pregnancy/lactation in adults). This phase assigns the pre-test AOM-vs-OME-vs-OE probability.
    inputs: acute_inflammation_signs, laterality_uni_vs_bilateral, otorrhoea_present, temperature, craniofacial_anomaly_or_immunocompromise
    actions: workup.pediatric_fever
    advance: AOM context + pretest AOM/OME/OE prior assigned
  4. 4RED_FLAGS
    Suppurative-complication screen — recognise then route OUT (NOT managed here): acute mastoiditis (post-auricular erythema/fluctuance, protruding pinna) → ENT/drainage; acute facial nerve palsy → workup.bells_palsy + urgent ENT; suppurative labyrinthitis (vertigo, nystagmus, SNHL) → ENT; intracranial extension (meningism, altered mental status, focal deficit, seizure → meningitis / sigmoid-sinus thrombosis / brain or epidural abscess) → id.bacterial-meningitis.core.v1 + workup.bacterial_meningitis; toxic child / sepsis → protocol.septic_shock / id.sepsis.core.v1.
    inputs: mastoiditis_signs, intracranial_or_neuro_red_flags
    actions: workup.bacterial_meningitis, workup.bells_palsy, calc.qsofa, protocol.septic_shock
    advance: complication red flags screened; positive findings routed OUT by engine_id with carryover
  5. 5INITIAL_WORKUP
    AOM is a CLINICAL otoscopic diagnosis — no routine bloods/imaging in uncomplicated disease. Document TM appearance (bulging/cloudy/erythema/perforation) and confirm a middle-ear effusion by pneumatic otoscopy ± tympanometry (the conditionally-dependent confirmatory pair). Bloods/CT/MRI only when a complication is suspected (mastoid CT, contrast MRI/MRV for intracranial extension) — driven from RED_FLAGS, not here.
    inputs: tm_appearance, middle_ear_effusion_present
    actions: calc.centor
    advance: otoscopic AOM criteria met (MEE + acute inflammation) and OME excluded; OR complication workup launched
  6. 6BRANCHING_WORKUP
    Branch on the otoscopic findings: effusion + bulging/marked-erythema/otorrhoea → AOM (proceed to the observe-vs-treat decision); effusion WITHOUT acute inflammation → OME (NOT antibiotics — hearing-surveillance pathway, AAO-HNS Rosenfeld 2022); tragal-traction pain + canal oedema/debris + obscured TM → otitis externa → route to ent.otitis-externa.core.v1 (topical-only); referred otalgia with a normal ear (pharyngitis/dental/TMJ/cervical) → calc.centor for pharyngitis arm and search the source; recurrent AOM → tympanostomy-tube candidacy (workup.lymphadenopathy off-path only if adenopathy/mass).
    inputs: middle_ear_effusion_present, tm_appearance
    actions: workup.lymphadenopathy, calc.centor
    advance: single best diagnosis assigned (AOM / OME / OE / referred otalgia) and look-alikes routed
  7. 7DIFFERENTIAL
    Terminal differential with named pivots: AOM vs OME (acute inflammation + moderate/severe bulge + otalgia/fever pivot — Rothman JAMA 2003 bulging LR+ 51) vs otitis externa (tragal/pinna-traction tenderness + canal oedema/debris + normal-or-obscured TM pivot — route to ent.otitis-externa.core.v1) vs bullous myringitis (haemorrhagic TM bullae — managed as AOM) vs referred otalgia (normal ear exam + extra-otologic source: pharyngitis/dental/TMJ/cervical spine pivot) vs mastoiditis (post-auricular swelling + protruding pinna pivot — route OUT).
    advance: single best diagnosis selected; OME/OE/referred-otalgia/complication coded and routed
  8. 8RISK_STRATIFICATION
    AAP 2013 observe-vs-treat stratification: <6 mo → always antibiotic; 6-23 mo with bilateral AOM OR any severe AOM OR otorrhoea → immediate antibiotic, else shared-decision observation option; ≥2 y nonsevere unilateral/bilateral without otorrhoea → observation option with a safety-net (delayed) prescription; severe AOM (moderate/severe otalgia, otalgia ≥48 h, or temp ≥39 °C) → immediate antibiotic at any age; craniofacial anomaly/immunocompromise/tube → excluded from observation. Toxic appearance/qSOFA-positive escalates.
    inputs: severe_aom_criteria, age_months, laterality_uni_vs_bilateral, otorrhoea_present
    actions: calc.qsofa, calc.sirs
    advance: observe-vs-immediate-antibiotic decision assigned per AAP 2013 age/severity/laterality/otorrhoea criteria
  9. 9TREATMENT
    MANDATORY analgesia in parallel at every step (ibuprofen/acetaminophen ± topical anaesthetic ear drops if TM intact — NICE NG91 [2022]) regardless of the antibiotic decision. Antibiotic ladder when indicated: high-dose amoxicillin 80-90 mg/kg/day divided BID first-line; amoxicillin-clavulanate if amoxicillin within 30 d, concurrent purulent conjunctivitis (conjunctivitis-otitis = H. influenzae), or failure at 48-72 h; penicillin allergy → cefdinir/cefuroxime/cefpodoxime (non-severe) or azithromycin/clindamycin (severe) or single-dose IM/IV ceftriaxone; tube/perforation in situ → TOPICAL ototopical drops only, no oral (AAO-HNS Rosenfeld 2022 KAS14). Duration: 10 d <2 y / severe / perforation; 5-7 d ≥2 y nonsevere (Hoberman NEJM 2016 — 5 d inferior in <2 y).
    inputs: antibiotic_in_prior_30_days, penicillin_allergy, tympanostomy_tube_or_perforation_in_situ, weight_kg, pregnancy_or_lactation
    advance: analgesia started; antibiotic decision executed (immediate / safety-net delayed / topical-only / none) with weight-based dose and duration; 48-72 h recheck plan set
  10. 10DISPOSITION
    Uncomplicated AOM → discharge home with analgesia ± antibiotic (immediate or safety-net delayed) and 48-72 h return/recheck advice. Severe AOM in <6 mo or toxic appearance → consider admission/ED workup. Any suppurative complication (mastoiditis, facial palsy, labyrinthitis, intracranial extension, sepsis) → admit and route OUT by engine_id (ENT / id.bacterial-meningitis.core.v1 / id.sepsis.core.v1). Recurrent AOM → ENT tympanostomy-tube referral.
    inputs: age_months, severe_aom_criteria
    advance: disposition documented; complications admitted/routed; recurrent-AOM referral made if criteria met
  11. 11MONITORING
    Reassess at 48-72 h: expect symptomatic improvement; persistent or worsening otalgia/fever at 48-72 h on appropriate therapy = treatment failure → step up amoxicillin → amoxicillin-clavulanate → ceftriaxone × 3 d (and re-examine for missed OME-not-AOM, otitis externa, or an evolving complication before silently extending duration). Counsel that MEE persists for weeks after AOM resolves and is OME (not relapse) — do not re-treat asymptomatic post-AOM effusion (AAP 2013; AAO-HNS Rosenfeld 2022).
    inputs: acute_inflammation_signs, temperature
    actions: workup.pediatric_fever
    advance: objective improvement by 48-72 h OR treatment-failure step-up triggered OR complication re-screen launched
  12. 12FOLLOWUP
    Post-AOM hearing/effusion surveillance — persistent MEE ≥3 mo or hearing concern → audiology + OME pathway (AAO-HNS Rosenfeld 2022). Recurrent AOM (≥3/6 mo or ≥4/12 mo with ≥1 recent) with MEE present → ENT tympanostomy-tube referral (Venekamp Cochrane 2018 — tubes vs active monitoring NNT ~3 at 6 mo). Modifiable-risk counselling: avoid supine bottle-feeding, tobacco-smoke exposure, ensure pneumococcal + influenza immunisation; breastfeeding is protective (AAP 2013 prevention section).
    inputs: recurrent_aom_3in6_or_4in12, craniofacial_anomaly_or_immunocompromise
    advance: hearing/effusion surveillance + recurrence/prevention plan documented; ENT referral made if tube criteria met