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Otorhinolaryngology›Condition·Updated Jul 11, 2026·v1

Acute Otitis Media

Acute otitis media (AOM) is a common acute infection of the middle ear, predominantly affecting children aged 6-24 months. Diagnosis relies on pneumatic otoscopy showing a bulging, opaque tympanic membrane with limited mobility. Management centers on analgesia and risk-stratified antibiotic use: immediate 10-day amoxicillin-clavulanate for children <2 years with bilateral AOM or otorrhea, and watchful waiting for mild, unilateral cases in older children. Complications are rare but include acute mastoiditis, labyrinthitis, and facial nerve palsy. Prevention through PCV13 and influenza vaccination is effective. Tympanostomy tubes are reserved for recurrent AOM with documented middle ear effusion.

High Evidence260 references·9,531 words·39 min read·v1
acute otitis mediapediatric otologymiddle ear infectionamoxicillin-clavulanatetympanostomy tubesmastoiditis

Quick Reference

RxDrug of choiceAmoxicillin-clavulanate 90 mg/kg/day (amoxicillin component) PO divided BID for 10 days
AltAlternativesCefdinir 14 mg/kg/day PO once or BID for 10 days (penicillin-allergic, non-IgE); Ceftriaxone 50 mg/kg IM/IV once daily for 3 days (severe allergy or treatment failure)
⊘AvoidAntihistamines, decongestants, corticosteroids (no benefit); non-dihydropyridine CCBs (exacerbate HF if concurrent); fluoroquinolones in pregnant women (category C in first trimester); tetracyclines in pregnancy (category D)
DxTest of choicePneumatic otoscopy (bulging, opacity, limited mobility) confirms diagnosis. Tympanometry and OCT are adjuncts in equivocal cases
ScKey scoreSeverity classification (mild/moderate/severe) integrating age, fever, otalgia, and TM bulging; bilateral AOM in child <2 years or otorrhea at any age identifies subgroups with largest antibiotic benefit (NNT 3-4)
→When to referENT referral for recurrent AOM with MEE (tympanostomy tubes), suspected complication (mastoiditis, facial palsy, labyrinthitis), or treatment failure after 48-72 hours of antibiotics
Analgesia is immediate cornerstone; antibiotics reserved for children <2 years with bilateral AOM or otorrhea (NNT 4) and severe cases; 10-day amoxicillin-clavulanate is standard; watchful waiting appropriate for mild, unilateral AOM in children >2 years
Acute otitis media (AOM) is an acute infection of the middle ear characterized by rapid-onset middle ear effusion and inflammation. It is the leading cause of pediatric healthcare visits and antibiotic prescriptions in the United States, though spontaneous resolution occurs in about 60% of children within 24 hours. This page synthesizes the evidence for diagnosis, risk stratification, medical and surgical management, and prevention of this common condition.

Overview and Recommendations

Background

  • •Acute otitis media (AOM) is an acute infection of the middle ear cleft, the tympanic cavity, eustachian tube, and mastoid air cells, that presents with rapid-onset middle ear effusion and signs of inflammation. It must be distinguished from otitis media with effusion (OME), which lacks acute inflammation, and from recurrent AOM (≥4 episodes per year) and chronic suppurative otitis media (CSOM, >6 weeks of discharge).
  • •AOM is predominantly a disease of early childhood: peak incidence occurs between 6 and 24 months, with a median of one episode per year in the second year of life. It accounts for approximately 15 million healthcare visits annually in the United States and is the most common indication for antibiotic therapy in children, though about 55-60% of untreated cases resolve spontaneously within 24-48 hours.
  • •The pathophysiologic cascade begins with viral upper respiratory infection (most often RSV) causing eustachian tube dysfunction, which creates negative middle ear pressure and draws nasopharyngeal secretions, containing Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis, into the sterile middle ear. Toll-like receptors and NOD-like receptors recognize bacterial components, triggering release of TNF-α, IL-1β, IL-6, and IL-8, which drive mucosal edema, neutrophil recruitment, and hyperplasia.
  • •Untreated or severe AOM can progress to complications in about 0.26% of emergency department visits: acute mastoiditis (0.16%), labyrinthitis (0.06%), and facial nerve paresis (0.03%). Intracranial extension (meningitis, sigmoid sinus thrombosis, brain abscess) is rare but carries significant morbidity. Extended high-frequency hearing loss (8-16 kHz) may persist even after standard audiometry normalizes, particularly when inflammation lasts >10 days.
  • •Key variants and severity grades inform management: bilateral AOM in children <2 years and AOM with otorrhea identify subgroups with the largest absolute antibiotic benefit (NNT 3-4). The Japanese severity classification (mild/moderate/severe) integrates age, fever, otalgia, and tympanic membrane bulging to guide initial therapy. Recurrent AOM (≥3 episodes in 6 months or ≥4 in 12 months) may warrant tympanostomy tube placement in children with documented middle ear effusion at the time of assessment.

Evaluation

  • •Suspect AOM in any child (especially aged 6-24 months) or adult with acute-onset ear pain (older children verbalize earache; infants present with crying, ear tugging, disturbed sleep), fever (present in ~50%, temperature ≥39°C increases likelihood), and hearing difficulty that may manifest as inattention. A preceding upper respiratory infection is common.
  • •Ask about otalgia severity, fever height, laterality, duration of symptoms (<48 hours suggests AOM vs OME), prior episodes (to identify recurrent AOM), daycare attendance, smoke exposure, breastfeeding history, and penicillin allergy.
  • •Examine the tympanic membrane (TM) using pneumatic otoscopy, the gold standard bedside tool. The three diagnostic criteria are: (1) bulging of the TM (most specific sign; positive likelihood ratio >20), (2) opacity with loss of normal landmarks, and (3) limited mobility on pneumatic insufflation. Erythema alone is insufficient (can result from crying or fever). Otorrhea (purulent drainage from a TM perforation) confirms diagnosis but occurs in only 5-10% of cases.
  • •Classify severity: mild disease (unilateral, mild otalgia, temperature <39°C, age >2 years, no otorrhea) vs severe disease (bilateral, severe otalgia, temperature ≥39°C, age <2 years, or otorrhea present). The Japanese guidelines further stratify into mild, moderate, and severe based on age, fever, and otoscopic findings.
  • •Order no routine imaging for uncomplicated AOM. Contrast-enhanced CT of temporal bone is indicated if complications are suspected: persistent fever >39°C, postauricular swelling/erythema (mastoiditis), facial nerve palsy, vertigo/nystagmus (labyrinthitis), or meningeal signs (intracranial extension). MRI with gadolinium better defines intracranial complications and serous labyrinthitis (3D FLAIR enhancement).
  • •Consider tympanometry and optical coherence tomography (OCT) as adjuncts in equivocal cases. Tympanometry classifies middle ear status (type A normal, type B effusion, type C negative pressure). OCT has 74% sensitivity and 93% specificity for middle ear effusion and changed diagnosis/treatment in 15.3% of children in one trial.
  • •In children with tympanostomy tubes presenting with otorrhea, diagnose acute tympanostomy tube otorrhea (AOMT). Examine for granulation tissue and debris. Topical antibiotic-corticosteroid drops are first-line; systemic antibiotics are not indicated for uncomplicated AOMT.
  • •Assess for risk factors for recurrence or complications: age <2 years, bilateral AOM, craniofacial anomalies (e.g., cleft palate), immunocompromise (including cochlear implants), chronic medical conditions (adjusted IRR 2.1 for ≥2 comorbidities), and 22q11.2 deletion syndrome (42.2% develop recurrent AOM).
  • •In adults, obtain a baseline audiogram if sensorineural hearing loss is suspected (tinnitus, vertigo, high-frequency loss). SNHL complicates AOM in 9.3% of adult cases, most commonly at high frequencies; recovery averages 18.6 days with treatment. Extended high-frequency audiometry (8-16 kHz) may detect residual cochlear damage not visible on standard testing.
  • •Also consider: OME (effusion without acute inflammation), CSOM (chronic perforation with discharge >6 weeks), and foreign body or otitis externa in children with otorrhea. Red flags requiring urgent ENT consultation: postauricular swelling/erythema/auricle protrusion (mastoiditis), facial nerve palsy, vertigo/nystagmus, and meningeal signs.

Management

  • •Initiate analgesia immediately for all children with AOM: administer paracetamol (acetaminophen) 15 mg/kg PO/PR every 4-6 hours as needed, or ibuprofen 10 mg/kg PO every 6-8 hours. Paracetamol may reduce pain at 48 hours (NNT 7). Topical anaesthetic drops lack sufficient evidence for routine use.
  • •For mild, unilateral AOM in children >2 years without otorrhea, offer watchful waiting with a safety-net antibiotic prescription. Spontaneous resolution occurs in ~60% within 24 hours and ~80% by 2-3 days. Antibiotics reduce pain at 2-3 days (NNT 20) but increase adverse events (NNT harm 14). Shared decision-making is essential.
  • •For children <2 years with bilateral AOM or any child with severe disease (age <2 years, bilateral, severe otalgia, fever ≥39°C, or otorrhea), prescribe antibiotics immediately. First-line: amoxicillin-clavulanate 90 mg/kg/day of the amoxicillin component PO divided twice daily for 10 days. This reduces clinical failure from ~23% to 4% at day 4-5 (NNT 5) in children 6-23 months.
  • •For penicillin-allergic patients (non-IgE mediated), use cefdinir 14 mg/kg/day PO once or divided twice daily for 10 days. For severe penicillin allergy (IgE-mediated), consider ceftriaxone 50 mg/kg IM/IV once daily for 3 days, then transition to oral therapy if defervescence occurs.
  • •Monitor for treatment response at 48-72 hours: if symptoms worsen or fail to improve, re-examine to confirm diagnosis and check for complications. For persistent severe disease, switch to ceftriaxone 50 mg/kg IM/IV daily for 3 days. Consider myringotomy (± tympanostomy tube) for toxic children with severe otalgia or persistent otorrhea despite topical therapy.
  • •For acute tympanostomy tube otorrhea (AOMT), treat with topical ciprofloxacin 0.3% plus fluocinolone 0.025% otic solution twice daily for 7 days, this is superior to ciprofloxacin alone (median time to cessation 4.23 vs 6.95 days; clinical cure 80.6% vs 67.4%). Oral antibiotics are not indicated for uncomplicated AOMT.
  • •Do NOT prescribe antihistamines or decongestants for AOM or OME, no benefit and increased side effects (NNH 9). Do NOT use oral or nasal corticosteroids for OME. Do NOT use antireflux therapy for AOM. Do NOT treat OME with antibiotics.
  • •Refer for tympanostomy tube evaluation in children with recurrent AOM (≥3 episodes in 6 months or ≥4 in 12 months) AND documented middle ear effusion at the time of assessment. Tubes do not significantly reduce the AOM rate over 2 years (1.48 vs 1.56 episodes per child-year, P=0.66) but improve secondary outcomes and quality of life.
  • •In children ≥4 years undergoing initial tympanostomy tube placement, consider concurrent adenoidectomy: it reduces the odds of repeat tube insertion (OR 0.46). For children without MEE at evaluation, 91% do not require tubes within one year; provide semiurgent return precautions for new AOM episodes.
  • •Admit for IV antibiotics and ENT consultation if: toxic appearance, age <6 months with severe disease, suspected suppurative complication (mastoiditis, facial palsy, labyrinthitis, intracranial extension), or inability to tolerate oral antibiotics. For acute mastoiditis with subperiosteal abscess, conservative management (IV antibiotics + myringotomy + needle aspiration) succeeds in 94% of cases; cortical mastoidectomy is reserved for failures.
  • •After resolution of the acute episode, assess for persistent middle ear effusion and manage per OME guidelines. If sensorineural hearing loss is suspected, refer for audiometry. For children with recurrent AOM despite tubes, evaluate for biofilm on the tube and consider tube removal/cleaning or topical therapy targeted to culture results.

Board Review — High Yield

  • •Pneumatic otoscopy, The three diagnostic criteria: bulging (LR+ >20), opacity with loss of landmarks, and limited mobility. Erythema alone is insufficient.
  • •Spontaneous resolution, 60% recover within 24 hours without antibiotics; watchful waiting is appropriate for mild, unilateral AOM in children >2 years.
  • •Antibiotic benefit subgroups, Bilateral AOM in children <2 years and AOM with otorrhea have NNT of 3-4; otherwise healthy children >2 years with unilateral mild AOM have NNT ~20.
  • •Amoxicillin-clavulanate 90 mg/kg/day, First-line for 10 days in children <2 years with severe disease; 5-day courses are inferior (34% vs 16% clinical failure).
  • •Topical ciprofloxacin-fluocinolone, First-line for acute tympanostomy tube otorrhea; faster cessation (4.23 vs 6.95 days) and higher cure (80.6% vs 67.4%) than antibiotic alone.
  • •Tympanostomy tubes, Do not reduce AOM rate over 2 years (1.48 vs 1.56 episodes/child-year, P=0.66) but improve secondary outcomes. Reserved for recurrent AOM with documented MEE.
  • •Acute mastoiditis, Most common complication (0.16% ED visits); treat with IV antibiotics and myringotomy ± needle aspiration; 94% resolve without mastoidectomy.
  • •Vaccination prevention, PCV13 reduced AOM hospitalizations by 34%; influenza vaccine modestly reduces AOM (RR 0.80, NNT 25).
  • •Extended high-frequency hearing loss, May persist after standard audiometry normalizes, especially if inflammation >10 days; consider EHF audiometry (8-16 kHz) in patients with tinnitus.
  • •Do NOT use antihistamines/decongestants, corticosteroids, or antireflux therapy for AOM or OME, no benefit and increased harm.

Deep Dive — Evidence Details

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