Usually precipitated by a viral upper respiratory tract infection that causes eustachian tube obstruction, resulting in accumulation of fluid and mucus, which become secondarily infected by bacteria

Nasotracheal intubation can cause otitis media

  • Most common pathogens

    • Streptococcus pneumoniae

    • Haemophilus influenzae

    • Streptococcus pyogenes

  • Chronic otitis media is usually not painful except during acute exacerbations

  • Most common in infants and children, although it may occur at any age

  • External otitis and acute otitis media are the most common causes of earache1



Physical Exam

  • Erythema and hypomobility of tympanic membrane


Laboratory Tests



Essentail Criteria to Establish Diagnosis


  • Image result for image otitis media

    Image result for image otitis mediaOtitis media (OM) is any inflammation of the middle ear without reference to etiology or pathogenesis.

  • Bacterial infection of the mucosally lined air-containing spaces of the temporal bone.

  • Purulent material forms within the middle ear cleft but also within the pneumatized mastoid air cells and petrous apex








Content 12

It is very common in children.



Depends on age, presence of fever, severity of illness

1. Pain control

2. Children <6 months: treated immediately with an appropriate antibiotic.

Systemic antibiotics used for the initial treatment of acute otitis media in children1
Antibiotic Route Dose Maximum daily dose
First-line agents
Amoxicillin Oral 90 mg/kg per day in two doses 3 g/day
Amoxicillin-clavulanate*¶ Oral 90 mg/kg per day in two doses 3 g/day (amoxicillin component)
Alternatives for children with mild or remote allergy to penicillins (ie, without anaphylaxis, bronchospasm, or angioedema)
Cefdinir Oral 14 mg/kg per day in one or two doses 600 mg/day
Cefpodoxime Oral 10 mg/kg per day in two doses 400 mg/day
Cefuroxime suspension¶Δ Oral 30 mg/kg per day in two doses 1 g/day
Ceftriaxone¶ Intramuscular or intravenous 50 mg/kg per day for one to three days 1 g/day
Alternatives for children with severe allergy◊ to beta-lactams including cephalosporins
Azithromycin Oral 10 mg/kg once on day one, then 5 mg/kg once per day on days two through five 500 mg/day on day one; 250 mg/day on days two through five
Clarithromycin§ Oral 15 mg/kg per day in two doses 1 g/day
Clindamycin Oral

10 to 25 mg/kg per day in three doses for mild to moderate infection 

30 to 40 mg/kg per day in three doses for severe infection

1.8 g/day
Erythromycin-sulfisoxazole Oral 50 mg/kg (erythromycin component) per day in three to four doses 2 g/day (erythromycin component)
* For children who have received a beta-lactam antibiotic (eg, penicillins, cephalosporins) in the previous 30 days or have concomitant purulent conjunctivitis or have a history of recurrent otitis media unresponsive to amoxicillin.
¶ Frequently used if amoxicillin fails.
Δ For children who can swallow tablets whole and weigh >17 kg, may use cefuroxime tablets; the dose is 250 mg twice daily.
◊ Anaphylaxis, angioedema, bronchospasm, urticaria where skin testing is unavailable or contraindicated (eg, for serious cutaneous reaction).
§ Infrequently used because of drug interactions.

3. Febrile infants younger than 60 days who are diagnosed with AOM may require additional evaluation before initiation of antimicrobial therapy to avoid masking an invasive bacterial infection. (See "Febrile infant (younger than 90 days of age): Outpatient evaluation", section on 'Ancillary studies'.)  

5. Children six months to two years with bilateral or unilateral AOM be treated immediately with an appropriate antibiotic.1

●We suggest that children ≥2 years who appear toxic; have persistent otalgia for more than 48 hours; have temperature ≥102.2°F (39°C) in the past 48 hours; have bilateral AOM or otorrhea; or have uncertain access to follow-up be immediately treated with an appropriate antibiotic. (See 'Initial antimicrobial therapy' below.)

●For children ≥2 years who are normal hosts (eg, immune competent, without craniofacial abnormalities) with mild symptoms and signs and no otorrhea, initial observation may be appropriate if the caretakers understand the risks and benefits of such an approach. (See 'Initial observation' below.)




Individual randomized trials that used stringent diagnostic criteria and experienced otoscopists to make the diagnosis of AOM and appropriate antibiotic regimens to treat AOM indicate that children younger than two years benefit from antibiotic therapy [35,36]. Pooled data from these trials indicate increased rates of treatment failure among placebo recipients <24 months with unilateral nonsevere AOM (40 versus 14 percent among antibiotic recipients; relative risk 0.34, 95% CI (0.18-0.65) [20]. These and other randomized trials suggest that children with "severe" (defined by fever and ear pain score) or bilateral AOM also benefit from antibiotic therapy [20,37,38].

The 2013 AAP and American Academy of Family Physicians (AAFP) guideline recommends immediate antimicrobial treatment for children <6 months, children with severe signs or symptoms (defined by moderate or severe ear pain, ear pain for ≥48 hours, or temperature ≥39°C [102.2°F]) and bilateral AOM in children <24 months of age [3]. The 2013 AAP/AAFP guideline recommends either immediate treatment or observation (with pain control) for children between 6 and 24 months with unilateral nonsevere AOM and for children ≥24 months with unilateral or bilateral nonsevere AOM. However, given the additional analysis now available showing a high rate of treatment failure among children <24 months with unilateral nonsevere AOM [20], we suggest that such children be treated at the time of diagnosis with antimicrobial therapy.

4. Guidelines from many other countries (eg, the Dutch College of General Practitioners) recommend a no or delayed antibiotic strategy for most children ≥6 months of age with AOM.






Management of OME primarily consists of watchful waiting. Most cases resolve spontaneously within 3 months; only 5% to 10% last 1 year or longer. Treatment depends on duration and associated conditions. The following options should be considered:

  • Document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME.6SOR C
  • Distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk.6SOR C Risk factors for developmental difficulties include:
    • Permanent hearing loss independent of OME.
    • Suspected or diagnosed speech and language delay or disorder.
    • Autism-spectrum disorder and other pervasive developmental disorders.
    • Syndromes (e.g., Down syndrome) or craniofacial disorders that include cognitive, speech, and language delays.
    • Blindness or uncorrectable visual impairment.
    • Cleft palate with or without associated syndrome.
    • Developmental delay.
  • Manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or diagnosis (if onset is unknown).6SOR B
  • Hearing testing is recommended when OME persists for 3 months or longer or at any time if language delay, learning problems, or significant hearing loss is suspected in a child with OME.6SOR B
  • Autoinflation with nasal balloon, in one systematic review, provided short-term benefits, although 12% of children ages 3 to 10 years were unable to use it.12


  • Oral acetaminophen (paracetamol) and ibuprofen may reduce earache when given with antibiotics.15 There is insufficient data to evaluate the effectiveness of topical analgesics in AOM.16SOR B
  • Antibiotics seem to be most beneficial in children younger than 2 years of age with bilateral AOM, high fever, or vomiting, and in children with both AOM and otorrhea. For most other children with mild disease, an observational policy seems justified.14,17SOR B
  • Antibiotics may lead to more rapid reduction in symptoms of AOM, but increase the risk of adverse effects, including diarrhea, vomiting, and rash.15SOR B
    • Antibiotics seem to reduce pain at 2 to 7 days, and may prevent development of contralateral AOM, but increase the risks of adverse effects compared with placebo.13
    • There is insufficient effectiveness data regarding which antibiotic regimen is better than another.13,15
    • Antibiotics found to be effective in AOM include amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, erythromycinazithromycin, trimethoprim-sulfamethoxazole, and cephalosporins. Amoxicillin is a good first-line treatment because it is inexpensive and children tolerate the bubblegum taste well.
    • Longer (8- to 10-day) courses of antibiotics reduce short-term treatment failure but have no long-term benefits compared with shorter regimens (5-day courses).15,18
    • An observational approach substantially reduces unnecessary use of antibiotics in children with AOM and may be an alternative to routine use of antimicrobials for treatment of such children.19
  • Immediate antibiotic treatment (i.e., given at initial consultation) may reduce the duration of symptoms of AOM, but increases the risk of vomiting, diarrhea, and rash compared with delayed treatment (i.e., given after 72 hours).15SOR B
  • Treatment of AOM with decongestants and antihistamines is not recommended.20SOR B
  • Antihistamines and decongestants are not effective for OME.6SOR A
  • Antimicrobials and corticosteroids are not recommended for OME.6SOR A

Complementary and Alternative Therapy

  • Evidence on whether zinc supplementation can reduce the incidence of otitis media in healthy children younger than the age of 5 years living in low- and middle-income countries is mixed.21SOR B


  • Refer to specialist (otolaryngologist, audiologist, or speech-language pathologist) if:6SOR C
    • Persistent fluid for 4 or more months with persistent hearing loss.
    • Associated speech delay.
    • Structural damage to TM or middle-ear.
  • Tympanostomy tubes for children with recurrent AOM (3 or more episodes of AOM in 6 months, or 4 or more AOM in 1 year) have a significant role in maintaining a “disease-free” state in the first 6 months after insertion. Because long-term effectiveness is uncertain, clinicians should consider possible adverse effects before surgery is undertaken.22SOR B
  • Insertion of tympanostomy tubes in young children with persistent middle-ear infection does not improve cognitive development, language acquisition, or speech development compared with waiting 6 to 9 months for the effusion to resolve before placing the tubes.23 Moreover, delayed insertion of tubes helps children avoid getting tubes altogether and does not result in worse developmental outcomes.24SOR A
  • When a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure; adenoidectomy should not be performed unless a distinct indication exists (e.g., nasal obstruction, chronic adenoiditis).6SOR B
  • Repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME.6SOR B


Content 4

Content 3

A 15-month-old boy has a 2-day history of fever, irritability, and frequent tugging of his left ear. This was preceded by a 1-week history of nasal congestion, cough, and rhinorrhea. On otoscopy, his left tympanic membrane (TM) appears erythematous, cloudy, bulging, and exudative.

Image not available.

Acute otitis media in the left ear of a 15-month-old patient with marked erythema and bulging of the tympanic membrane. The malleus and light reflex are not visible. (William Clark, MD.)



His left TM fails to move on pneumatic otoscopy. The physician diagnoses acute otitis media and decides with the parents to prescribe a 10-day course of amoxicillin; the child recovers uneventfully.



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