Updated NICE Guidance on Otitis Media Treatment

Dr Sheena Meredith

March 14, 2022

Updated guidance on acute otitis media from the National Institute for Health and Care Excellence (NICE) recommends that anaesthetic and analgesic ear drops be considered for initial treatment of acute otitis media (AOM). The update is intended to reduce antibiotic use.

The current NICE guideline, first issued in 2018, advised that most common ear infections should not be treated with antibiotics, as most children and young people improve without them within 3 days anyway, and serious complications are rare. Recommended treatment options included pain relief with oral analgesics with the option of a back-up antibiotic prescription. Immediate antibiotics were only recommended for those most likely to benefit - children under 2 with bilateral infection or those of any age with ear discharge.

Only One Combined Ear Drop Prescription Available

In the new update, NICE says that anaesthetic and analgesic ear drops can be used for AOM if an immediate antibiotic prescription is not given and there is no ear drum perforation or otorrhoea. Currently in England, there is only one combined preparation of anaesthetic/analgesic ear drops available – Otigo (POM, Renascience Pharma Ltd), which contains lidocaine hydrochloride 10 mg and phenazone 40 mg. The recommended dosage for all ages is 4 drops into the external auditory canal 2-3 times a day for up to a week.

NICE pointed out that there are about 896,000 episodes of AOM in children aged 0 to 5 years old in England each year. Of these, 524,000 are estimated to have AOM with no ear drum perforation or otorrhoea, so would be eligible for pain treatment with anaesthetic/analgesic ear drops. However there is currently minimal use of ear drops and routine treatment more often centres on oral paracetamol or ibuprofen to manage pain associated with AOM.

Evidence Shows Antibiotics are Not Needed by Most Children

Introducing the updated guidance, Dr Paul Chrisp, director of NICE’s centre for guidelines, said: "Based on evidence, our committee agreed that ear drops containing an anaesthetic and an analgesic may reduce antibiotic consumption and relieve pain in children who did not need immediate antibiotics.

"The evidence shows antibiotics are not needed by most children and young people with middle ear infections. We must make sure the people who need them are given them, but routine prescribing in all cases isn’t appropriate.

"We will continue to monitor new studies or treatments, which could be relevant to and impact on our guidelines to ensure that our advice and information remains as up to date as possible."

The new guideline includes a visual summary of the recommendations setting out an antimicrobial prescribing strategy for AOM that aims to limit antibiotic use and reduce antimicrobial resistance.


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