How should I manage a patient with otitis media who has a history of frequent ear infections?

Management of a patient with otitis media and a history of frequent ear infections (recurrent acute otitis media, AOM):

• Define recurrent AOM as three or more episodes in 6 months, or four or more episodes in 12 months with at least one episode in the past 6 months.
• Manage acute episodes of recurrent AOM similarly to initial presentations, including symptomatic treatment with regular paracetamol or ibuprofen for pain relief, appropriate to age and weight.
• If the patient has not taken antibiotics for the current episode, prescribe a 5–7 day course of amoxicillin; if allergic to penicillin, use clarithromycin or erythromycin (erythromycin preferred in pregnancy).
• If symptoms worsen despite first-line antibiotics after 2–3 days, prescribe a second-line antibiotic such as co-amoxiclav; seek specialist advice if penicillin-allergic.
• Consider referral to an Ear, Nose and Throat (ENT) specialist for patients with recurrent AOM, especially adults with more than two episodes per year or children meeting the recurrent criteria, particularly if conservative management is ineffective.
• Referral is also advised if episodes are unexplained, if there is suspicion of cholesteatoma, or if symptoms persist despite two courses of antibiotics.
• For patients with tympanostomy tubes (grommets) who present with acute discharge, take an ear swab for culture and sensitivity and manage accordingly.
• Advise patients and carers about self-care, including the lack of evidence for decongestants or antihistamines, and the importance of pain management.

Summary: Treat acute episodes as new infections with appropriate antibiotics and analgesia, monitor response, and refer to ENT for recurrent or complicated cases to consider interventions such as tympanostomy tubes (grommets) or specialist assessment ¹.