Acute otitis media

Last Updated on by frcemuser

Acute otitis media (AOM) is defined as the presence of inflammation in the middle ear, associated with effusion and accompanied by the rapid onset of symptoms and signs of an ear infection.

AOM may be caused by viral or bacterial infection. The most common bacterial pathogens are Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Streptococcus pyogenes. The most common viral pathogens associated with AOM are respiratory syncytial virus (RSV) and rhinovirus.

AOM occurs frequently in children but is less common in adults; 75% of episodes of AOM occur in children < 10 years old. Males are affected slightly more often than females.

Potential complications of AOM include:

  • recurrence of infection
  • hearing loss (conductive and usually temporary) tympanic membrane perforation
  • rarely mastoiditis, meningitis, intracranial abscess, sinus thrombosis and facial nerve palsy.

Clinical features include earache, and in younger children – pulling, tugging, or rubbing of the ear, or non-specific symptoms such as fever, irritability, crying, poor feeding, restlessness at night, cough, or rhinorrhoea. On examination there may be a distinctly red, yellow or cloudy tympanic membrane, moderate to severe bulging of the tympanic membrane with loss of normal landmarks, an air-fluid level behind the tympanic membrane and perforation of the tympanic membrane +/- discharge into the external auditory canal.


  • Children younger than 3 months with a temperature of 38oC or patients with suspected acute complications should be admitted for urgent assessment.
  • Consider admitting people who are systemically unwell, children younger than 3 months or children aged 3– 6 months with a high fever (> 39oC).
  • Treat pain and fever with paracetamol or NSAID such as ibuprofen.
  • For most people, consider either a no antibiotic prescribing policy (reassure that symptoms will likely get better on their own without treatment and antibiotics may have adverse effects e.g. diarrhoea, vomiting, rash) or a delayed antibiotic policy (advise that antibiotics should only be started if symptoms are not improving within 4 days of symptom onset or if there is significant worsening of symptoms).
  • Offer immediate antibiotic prescription to people who are systemically unwell but do not require admission, people who are at high risk of complications (e.g. immunocompromised or comorbidities) and people whose symptoms have lasted for 4 days or more and are not improving.
  • Consider offering immediate antibiotic prescription to children who are < 2 years with bilateral AOM, or children with perforation +/- discharge in the ear canal.
  • If an antibiotic is required, first line is a 5 day course of amoxicillin. Routine follow up is not required.


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