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Otitis Media (Acute)

By Richard T. Miyamoto, MD, MS, Arilla Spence DeVault Professor Emeritus and Past-Chairman, Department of Otolarynology - Head and Neck Surgery, Indiana University School of Medicine

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Patient Education

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 acute otitis media 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 of acute otitis media 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.

Risk factors

The presence of smoking in the household is a significant risk factor for acute otitis media. Other risk factors include a strong family history of otitis media, bottle feeding (ie, instead of breastfeeding), and attending a day care center.


Complications of acute otitis media are uncommon. 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.


  • Clinical evaluation

Diagnosis of acute otitis media usually is clinical, based on the presence of acute (within 48 h) onset of pain, bulging of the TM and, particularly in children, the presence of signs of middle ear effusion on pneumatic otoscopy. Except for fluid obtained during myringotomy, cultures are not generally done.


  • Analgesics

  • Sometimes antibiotics

  • Rarely myringotomy

Analgesia should be provided when necessary, including to pre-verbal children with behavioral manifestations of pain (eg, tugging or rubbing the ear, excessive crying or fussiness). Oral analgesics, such as acetaminophen or ibuprofen, are usually effective; weight-based doses are used for children. A variety of topical agents are available by prescription and over the counter. Although not well studied, some topical agents may provide transient relief but probably not for more than 20 to 30 min. Topical agents should not be used when there is a TM perforation.

Although 80% of cases resolve spontaneously, in the US, antibiotics are often given ([1]; see Table: 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 certain children (eg, those who are younger or more severely ill—see Table: Guidelines for Using Antibiotics in Children With 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 48 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. Decision to observe should be discussed with the caregiver.

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

Preferred unless the child has one of the following:

  • Received amoxicillin in the past 30 days

  • Purulent conjunctivitis

  • Recurrent acute otitis media unresponsive to amoxicillin

High-dose regimen for possible resistant organisms



14 mg/kg once/day or 7 mg/kg q 12 h


< 14 yr: 15 mg/kg q 12 h

> 14 yr: 500 mg q 12 h

Maximum 1000 mg/day


5 mg/kg q 12 h


50 mg/kg IM or IV once

May repeat at 72 h

Consider particularly for children with severe vomiting or who will not swallow antibiotic liquids

Resistant cases


< 14 yr: 40–45 mg/kg q 12 h

14 yr: 500 mg q 12 h

Preferred; dose based on amoxicillin component

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


50 mg/kg IM or IV once/day for 3 days

Can use even if failed on oral cephalosporin

Considered if adherence is likely to be poor


10 to 13 mg/kg q 8 h

2nd-line alternative, consider using along with a cephalosporin

*Treatment duration is typically 10 days for children < 2 yr and 7 days for older children unless otherwise specified. Drugs are given orally unless otherwise specified.

Cross reactivity of 2nd- and 3rd-generation cephalosporins with penicillin is very low.

No improvement after 48 to 72 h of treatment, or previous resistant infection; amoxicillin used in the previous 30 days; or concurrent purulent conjunctivitis

Data from Lieberthal AS, Carroll AE, Chonmaitree T, et al: The diagnosis and management of acute otitis media. Pediatrics e964–99, 2013.

Guidelines for Using Antibiotics in Children With Acute Otitis Media*



Severe symptoms (unilateral or bilateral)

Bilateral disease

Unilateral disease, no severe symptoms

< 6 mo





6 mo to 2 yr




Antibiotics or observe 48 to 72 h§

2 yr



Antibiotics or observe 48 to 72 h§

Antibiotics or observe 48 to 72 h§

*These guidelines apply only to children who meet the diagnostic criteria for acute otitis media (eg, acute [within 48 h] onset of pain, bulging of the tympanic membrane, and signs of middle ear effusion on pneumatic otoscopy).

Symptoms include temperature 39° C rectally any time within previous 24 h or moderate to severe otalgia for > 48 h, or physician’s judgment that child is seriously ill.

The guidelines in the Pediatrics article from which this table was derived do not include this age group in which observation has not been thoroughly studied. Thus it is reasonable to continue to treat with antibiotics.

§Decision making should be shared with parents. Observation is appropriate only if phone or office follow-up can be assured within 48 to 72 h; antibiotics are started if no improvement.

Modified from Lieberthal AS, Carroll AE, Chonmaitree T, et al: The diagnosis and management of acute otitis media. Pediatrics e964–99, 2013.

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.

Treatment reference


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. Prophylactic antibiotics are not recommended for children who have recurrent episodes of AOM.

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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