Acute Otitis Media

Core take-home message

Acute otitis media is common, usually self-limiting, and should be managed primarily with analgesia, not automatic antibiotics. Diagnosis requires acute symptoms plus abnormal ear findings, especially middle-ear effusion and inflammation. A red tympanic membrane alone is not enough. In a sick febrile child, do not assume AOM is the only diagnosis until serious illness such as meningitis, sepsis or mastoiditis has been considered.

1. Definitions

Acute Otitis Media (AOM)

Middle ear effusion plus acute inflammatory features:

Bulging TM
Red/opaque TM
Ear pain
Fever
Irritability
Otorrhoea/perforation

AOM with Perforation (AOMwiP)

Pus discharging through perforated TM for <2 weeks.

Otitis Media with Effusion (OME / Glue Ear)

Middle ear fluid without acute infection symptoms.

Recurrent AOM

≥3 episodes in 6 months OR
≥4 episodes in 12 months.

Chronic Suppurative Otitis Media (CSOM)

Persistent ear discharge through TM perforation for >2 weeks.

based on Otoscopic Findings

Normal TM

Translucent
Visible landmarks
Vertical malleus
No erythema

Viral / Injected TM

Pink/red TM
Transparent
No effusion
TM landmarks visible

AOM

Bulging
Opaque TM
Loss of landmarks
May appear red or white/yellow due to pus

OME (“Glue Ear”)

Retracted TM
Air-fluid level
Amber/yellow appearance
Reduced mobility

Otitis Externa

Tender ear canal
Swollen external canal
Thin pus/discharge

2. Epidemiology

AOM is very common in childhood:

Around 75% of children have at least one episode by school age.
Peak age is 6–18 months.
Most cases are viral, bacterial, or mixed viral-bacterial.

Common bacterial pathogens:

Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis

3. Risk factors

General risk factors

Recent viral URTI
Childcare exposure
Passive smoke exposure
Allergic rhinitis
Adenoid disease
Crowded living conditions
Socioeconomic disadvantage
Family history of chronic ear disease

Higher-risk children

Antibiotic treatment and closer follow-up are more likely to be required in:

Age <6 months
Systemically unwell child
Bilateral AOM in children <2 years
Otorrhoea or perforation
Aboriginal and Torres Strait Islander children at high risk
Cochlear implant
Immunodeficiency
Craniofacial abnormality, including cleft palate
Down syndrome
Developmental delay
Only hearing ear
Previous recurrent AOM or CSOM

4. Diagnosis

Diagnostic requirements

AOM diagnosis requires:

Acute onset symptoms, and
Middle-ear inflammation, and
Middle-ear effusion.

Symptoms

Common symptoms include:

Ear pain
Irritability in preverbal children
Fever
Poor feeding
Vomiting
Lethargy
Reduced sleep
Ear discharge if perforated

Important diagnostic warning

AOM should not be accepted as the only diagnosis in a sick febrile young child. Serious causes of fever must be considered, especially:

Sepsis
Meningitis
Mastoiditis
Pneumonia
UTI
Other systemic infection

5. Otoscopy: what to look for

Normal tympanic membrane

Translucent
Malleus visible
No erythema
Normal landmarks

Red or injected tympanic membrane

A red TM alone is not diagnostic of AOM. It can occur with:

Fever
Crying
Viral URTI
Eustachian tube dysfunction

In this situation, the TM is usually still transparent and landmarks remain visible.

AOM tympanic membrane

Typical AOM findings:

Bulging TM
Opaque TM
Loss of landmarks
Red, white or yellow appearance
Reduced mobility if pneumatic otoscopy available

Bulging is the strongest otoscopic clue.

Otitis media with effusion (OME) “glue ear” tympanic membrane

Features suggestive of glue ear:

Retracted TM
Prominent malleus
Amber or yellow fluid
Air-fluid level
Reduced mobility
Type B tympanogram if tested

Otitis externa

Differentiate from AOM with discharge:

Ear canal tenderness
Swollen external canal
Thin pus or debris
Pain with tragal or pinna movement
Canal disease rather than middle-ear disease

6. Investigations

Routine investigations

No routine diagnostic investigations are required for uncomplicated AOM.

Imaging

CT or MRI is generally only required if intracranial complication or mastoiditis is suspected.

Tympanometry / audiology

Useful when:

Diagnosis uncertain
Suspected OME
Persistent effusion
Hearing concerns
Speech/language delay
Recurrent OM
High-risk children

Persistent effusion beyond 3 months should trigger hearing assessment and ENT involvement/referral.

7. Management of uncomplicated AOM

First-line management: analgesia

Pain relief is the key treatment:

Paracetamol
Ibuprofen if appropriate
Regular dosing for the first 24–48 hours rather than only PRN if significant pain

The RACGP resource emphasises that most children do not require antibiotics and that oral analgesia is the mainstay.

Antibiotic use for acute otitis media in children – RACGP Download

Topical analgesia

Short-term topical analgesia may help severe acute ear pain if the tympanic membrane is intact:

2% lignocaine drops, or
Benzocaine + phenazone preparations

Avoid topical analgesic drops if perforation is suspected.

Treatments not recommended

Do not routinely use:

Decongestants
Antihistamines
Oral corticosteroids

These are not effective for AOM.

8. Antibiotics: why they are not routine

Most AOM resolves without antibiotics. In low-risk children, benefit is modest.

Evidence summary:

Antibiotics do not reduce pain at 24 hours.
Around 60% of children recover or improve by 24 hours.
Average symptom duration is shortened by only about 12 hours.
For every 100 children treated:
- Only ~5 additional children improve by 2–3 days
- Symptoms shortened by only ~12 hours on average
1 in 14 children treated will have an antibiotic adverse effect.

Potential harms:

Diarrhoea
Vomiting
Rash
Hypersensitivity
Individual and household bacterial resistance
Community antimicrobial resistance

9. When to use antibiotics

Antibiotics are recommended or strongly considered when the risk of complications or persistent disease is higher.

Prescribe antibiotics for:

Child <6 months
Systemically unwell child: lethargic, pale, very irritable
Child <2 years with bilateral AOM
AOM with otorrhoea/perforation
High-risk Aboriginal and Torres Strait Islander child
Cochlear implant
Immunodeficiency
Craniofacial abnormality
Down syndrome or significant developmental delay
Only hearing ear
History of CSOM or recurrent AOM

Typical antibiotic options

Common first-line:

Amoxicillin – 25–30 mg/kg/dose BD for 5–7 days depending on guideline/context.

Common escalation or alternative:

Consider Amoxicillin-Clavulanate If:
- Recent amoxicillin use
- Purulent conjunctivitis
- Recurrent AOM
- Failure of first-line therapy

Dose and duration vary by guideline and child risk profile. Local antimicrobial guidance should be followed.

10. Watchful waiting / delayed prescribing

For low-risk children aged ≥6 months with uncomplicated AOM:

Appropriate in low-risk children:

Review within 48–72 hours
Safety-net carefully
Consider delayed script strategy

Parents should seek review if:

Child worsens
Persistent pain
Ongoing fever
Hearing concerns
Persistent symptoms >2–3 months

Parent adviceExpl/ain:

AOM usually improves over about 3 days.
Symptoms may last up to 1 week.
Pain relief is important.
Antibiotics offer only small benefit for most children.
Return urgently if red flags occur.

11. Red flags and complications

Seek urgent review / hospital assessment if:

Toxic or systemically unwell child
Persistent lethargy
Neck stiffness
Photophobia
Altered consciousness
Persistent vomiting
Severe headache
Focal neurology
Seizure
Post-auricular swelling/redness/tenderness
Protruding pinna
Facial weakness
Cochlear implant with suspected AOM

Acute mastoiditis

Mastoiditis is rare but is the most common suppurative complication of AOM.

Features:

Pain or tenderness behind ear
Redness behind ear
Swelling behind ear
Ear protrusion
Fever
Irritability
Headache
Hearing loss
Otorrhoea

Management:

Urgent ENT / paediatric discussion
Hospital referral
IV antibiotics
Possible surgery

Other complications

Facial nerve palsy
Intracranial abscess
Meningitis
Subdural empyema
Venous sinus thrombosis
Tympanic membrane atelectasis
Cholesteatoma
Conductive hearing loss

12. Otitis media with effusion (OME)

Key concept

OME is fluid without acute infection symptoms. It is common after AOM and often resolves spontaneously. Antibiotics and ENT referral are not routinely required initially.

Clinical issue

The main concern is hearing loss, especially if persistent during language development.

Management

Usually no antibiotics
Usually no ENT referral initially
Observe and monitor hearing/language development
Refer If:
- Effusion >3 months
- Hearing loss
- Speech/language concerns
- Developmental concern

13. Aboriginal and Torres Strait Islander children

Why management differs

Kimberley Clinical Protocols- Ear Problems in Children Download

Kimberley Clinical Protocols- Ear Problems in Children

In many Aboriginal and Torres Strait Islander communities, OM is more common, starts earlier, lasts longer, and has greater risk of chronic suppurative disease and hearing loss.

current guidelines frames OM in Aboriginal children as a chronic disease requiring active follow-up, rather than a simple episodic acute illness.

Important consequences

Chronic OM can affect:

Hearing
Speech and language
Education
Behaviour
Psychosocial development
Long-term employment and wellbeing

Surveillance approach

For high-risk communities:

Check ears at every clinic visit.
Use otoscopy routinely.
Use tympanometry when available.
Ask carers about hearing, behaviour, learning and speech.
Use recall systems for persistent or recurrent disease.
Refer early for audiology, ENT, paediatrics or speech pathology when indicated.

14. Chronic suppurative otitis media

Definition

Persistent discharge through a TM perforation for >2 weeks.

Key management principles

Clean ear canal by dry mopping or syringing if appropriate.
Use topical ciprofloxacin drops where indicated.
Review weekly until dry.
Refer for diagnostic audiology at diagnosis.
ENT referral if discharge persists despite appropriate management.
Primary care remains responsible for active follow-up even after ENT referral.

Cholesteatoma suspicion

Urgent ENT review if:

Persistent unilateral discharge not responding to treatment
Attic perforation
Persistent crusting/granulation
Vertigo
Facial weakness
Intracranial infection features

15. Prevention

Preventive measures include:

Exclusive breastfeeding for first 6 months
Pneumococcal vaccination
Influenza vaccination
Avoid passive smoke exposure
Reduce dummy use after 6 months
Hand and face hygiene
Keep sick children away from babies where practical
Early review for ear pain or discharge

16. Practical GP approach

Step 1: Is the child sick?

Assess:

General appearance
Hydration
Work of breathing
Conscious state
Meningism
Sepsis features
Mastoid signs

If sick, do not stop at “ear infection”; consider serious illness.

Step 2: Is this truly AOM?

Look for:

Acute symptoms
Bulging TM
Opaque TM
Middle-ear effusion
Otorrhoea not due to otitis externa

Red TM alone is insufficient.

Step 3: Is the child high risk?

High-risk status changes management. Consider:

Age <6 months
<2 with bilateral AOM
ATSI high-risk child
Cochlear implant
Immunocompromise
Craniofacial abnormality
Recurrent AOM/CSOM
Systemically unwell

Step 4: Treat pain

Analgesia is essential whether or not antibiotics are prescribed.

Step 5: Decide antibiotics vs watchful waiting

Low-risk, mild AOM: analgesia + watchful waiting.
High-risk or complicated AOM: antibiotics + follow-up.

Step 6: Safety-net

Advise review if:

Worsening
Persistent fever
Poor oral intake
Drowsiness
Vomiting
Post-auricular swelling
Ear protrusion
Neck stiffness
Facial weakness
Persistent discharge
Hearing concerns

17. clinical pearls

AOM = acute symptoms + middle-ear inflammation + effusion.
Bulging TM is more useful than redness.
Red TM alone is often viral URTI or fever-related.
Most AOM resolves without antibiotics.
Analgesia is the main treatment.
Antibiotics have modest benefit but real harms.
Watchful waiting is appropriate in low-risk children.
A sick febrile child needs broader assessment, not just ear diagnosis.
OME is not AOM and usually does not need antibiotics.
Persistent OME >3 months needs hearing assessment.
ATSI children in high-risk settings need more active surveillance and follow-up.
Mastoiditis = post-auricular inflammation/protruding ear + unwell child → urgent ENT/hospital.