How should I manage a patient with recurrent otitis media who has not responded to first-line antibiotic treatment?

Management of a patient with recurrent otitis media who has not responded to first-line antibiotic treatment:

• Reassess the diagnosis to confirm whether the patient has otitis media with effusion (OME) or another form of otitis media, as the NICE guideline NG233 focuses on OME and does not cover acute or chronic otitis media management. For acute otitis media, refer to the specific NICE guideline on antimicrobial prescribing for acute otitis media.
• For OME, do not offer further antibiotics as treatment, since antibiotics are not recommended for OME management due to lack of benefit and potential harms.
• Consider referral for formal assessment including clinical examination (otoscopy), hearing testing, and tympanometry to evaluate the presence and impact of effusion and hearing loss.
• If hearing loss is confirmed and persistent, discuss management options such as monitoring, supportive strategies, auto-inflation, hearing aids (air or bone conduction devices), or surgical options like grommet insertion with or without adjuvant adenoidectomy.
• Discuss the benefits and risks of surgical interventions with the patient and/or their carers, including potential complications such as eardrum perforation and infection.
• Advise on supportive strategies to minimize the impact of hearing loss on daily living and communication.

In summary, for recurrent otitis media not responding to first-line antibiotics, avoid further antibiotic use if OME is diagnosed, proceed with formal assessment, and consider non-antibiotic management including hearing support and possible surgical referral based on hearing loss and clinical findings ¹.