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Otitis Media (Acute)

by Richard T. Miyamoto, MD, MS

Acute otitis media (AOM) is a bacterial or viral infection of the middle ear, usually accompanying a URI. Symptoms include otalgia, often with systemic symptoms (eg, fever, nausea, vomiting, diarrhea), especially in the very young. Diagnosis is based on otoscopy. Treatment is with analgesics and sometimes antibiotics.

Although AOM can occur at any age, it is most common between ages 3 mo and 3 yr. At this age, the eustachian tube is structurally and functionally immature, the angle of the eustachian tube is more horizontal, and the angle of the tensor veli palatini muscle and the cartilaginous eustachian tube renders the opening mechanism less efficient.

The etiology may be viral or bacterial. Viral infections are often complicated by secondary bacterial infection. In neonates, gram-negative enteric bacilli, particularly Escherichia coli, and Staphylococcus aureus cause AOM. In older infants and children < 14 yr, the most common organisms are Streptococcus pneumoniae, Moraxella (Branhamella) catarrhalis, and nontypeable Haemophilus influenzae; less common causes are group A β-hemolytic streptococci and S. aureus. In patients > 14 yr, S. pneumoniae, group A β-hemolytic streptococci, and S. aureus are most common, followed by H. influenzae.

In rare cases, bacterial middle ear infection spreads locally, resulting in acute mastoiditis, petrositis, or labyrinthitis. Intracranial spread is extremely rare and usually causes meningitis, but brain abscess, subdural empyema, epidural abscess, lateral sinus thrombosis, or otitic hydrocephalus may occur. Even with antibiotic treatment, intracranial complications are slow to resolve, especially in immunocompromised patients.

Symptoms and Signs

The usual initial symptom is earache, often with hearing loss. Infants may simply be cranky or have difficulty sleeping. Fever, nausea, vomiting, and diarrhea often occur in young children. Otoscopic examination can show a bulging, erythematous tympanic membrane (TM) with indistinct landmarks and displacement of the light reflex. Air insufflation (pneumatic otoscopy) shows poor mobility of the TM. Spontaneous perforation of the TM causes serosanguineous or purulent otorrhea.

Severe headache, confusion, or focal neurologic signs may occur with intracranial spread of infection. Facial paralysis or vertigo suggests local extension to the fallopian canal or labyrinth.


Diagnosis usually is clinical. Except for fluid obtained during myringotomy, cultures are not generally done.


  • Analgesics

  • Sometimes antibiotics

  • Rarely myringotomy

Although 80% of cases resolve spontaneously, in the US, antibiotics are often given ( Antibiotics for Otitis Media). Antibiotics relieve symptoms quicker (although results after 1 to 2 wk are similar) and may reduce the chance of residual hearing loss and labyrinthine or intracranial sequelae. However, with the recent emergence of resistant organisms, pediatric organizations have strongly recommended initial antibiotics only for children at highest risk (eg, those who are younger or more severely ill— Guidelines for Using Antibiotics in Acute Otitis Media) or for those with recurrent AOM (eg, 4 episodes in 6 mo). Others, provided there is good follow-up, can safely be observed for up to 72 h and given antibiotics only if no improvement is seen; if follow-up by phone is planned, a prescription can be given at the initial visit to save time and expense.

Antibiotics for Otitis Media


Dose* (by Age)


Initial treatment


< 14 yr: 40–45 mg/kg q 12 h

> 14 yr: 500 mg q 8 h


High-dose regimen for possible resistant organisms



< 14 yr: 10–12.5 mg/kg qid

Dose based on the sulfisoxazole component

Sulfonamides contraindicated in infants < 2 mo


14 yr: 250 mg po q 6 h


< 14 yr: 10 mg/kg on day 1, then 5 mg/kg once/day for 4 days

> 14 yr: 500 mg on day 1, then 250 mg once/day for 4 days

Shorter course, once/day

More expensive


> 2 mo: 4/20 mg/kg q 12 h

14 yr: 160/800 mg q 12 h

Sulfonamides contraindicated in infants < 2 mo

Resistant cases (no improvement after 72-h of treatment)


< 14 yr: 10–20 mg/kg q 12 h

14 yr: 250 mg q 8 h


< 14 yr: 15 mg/kg q 12 h

> 14 yr: 500 mg q 12 h

Maximum 1000 mg/day


< 14 yr: 40–45 mg/kg q 12 h

14 yr: 500 mg q 12 h

Dose based on amoxicillin component

Use new formulation to limit clavulanate to maximum of 10 mg/kg/day


< 14 yr: 7.5 mg/kg q 12 h

14 yr: 250 mg q 12 h



50 mg/kg IM once

Repeat at 24 and 48 h if case is resistant

Considered if adherence is likely to be poor

*Treatment duration is typically 10 to 12 days unless otherwise specified. Drugs are given orally unless otherwise specified.

Other drugs include cefdinir, cefpodoxime, ceftibuten, and clindamycin.

Guidelines for Using Antibiotics in Acute Otitis Media


Diagnosis Certain

Diagnosis Uncertain

< 6 mo



6 mo to 2 yr


Antibiotics if illness is severe*

Observe 72 h if illness is not severe

2 yr

Antibiotics if illness is severe

Observe 72 h if illness is not severe

Observe 72 h

*Temperature 39.5° C rectally any time within previous 24 h, moderate to severe otalgia, or physician’s judgment that child is seriously ill.

Appropriate only if phone or office follow-up assured within 72 h; antibiotics started if no improvement.

Modified from Rosenfeld RM: Observation option toolkit for acute otitis media. International Journal of Pediatric Otorhinolaryngology 58:1–8, 2001.

All patients receive analgesics (eg, acetaminophen, ibuprofen). In adults, topical intranasal vasoconstrictors, such as phenylephrine 0.25% 3 drops q 3 h, improve eustachian tube function. To avoid rebound congestion, these preparations should not be used > 4 days. Systemic decongestants (eg, pseudoephedrine 30 to 60 mg po q 6 h prn) may be helpful. Antihistamines (eg, chlorpheniramine 4 mg po q 4 to 6 h for 7 to 10 days) may improve eustachian tube function in people with allergies but should be reserved for the truly allergic. For children, neither vasoconstrictors nor antihistamines are of benefit.

Myringotomy may be done for a bulging TM, particularly if severe or persistent pain, fever, vomiting, or diarrhea is present. The patient’s hearing, tympanometry, and TM appearance and movement are monitored until normal.


Routine childhood vaccination against pneumococci (with pneumococcal conjugate vaccine), H. influenzae type B, and influenza decreases the incidence of AOM. Infants should not sleep with a bottle, and elimination of household smoking may decrease incidence.

Key Points

  • Give analgesics to all patients.

  • Antihistamines and decongestants are not recommended for children; oral or nasal decongestants may help adults, but antihistamines are reserved for adults with an allergic etiology.

  • Antibiotics should be used selectively based on the age of the patient, severity of illness, and availability of follow-up.

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