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Acute otitis media

Last updated: September 21, 2021

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Acute otitis media (AOM) is a painful infection of the middle ear that most commonly results from a bacterial superinfection with Streptococcus pneumoniae, Haemophilus influenza, or Moraxella catarrhalis following a viral upper respiratory tract infection. AOM is a common infection in children under the age of 2 years and is characterized by an acute onset of symptoms (e.g., otalgia, fever, anorexia) with signs of middle ear inflammation (e.g., bulging tympanic membrane, erythema). Mild unilateral infections can be managed without antibiotics, as they are often self-limiting. Infections in children under 6 months, bilateral AOM, or severe symptoms are usually treated with oral antibiotics. Most children will experience at least one episode before the age of five; in children with recurrent AOM that causes frequent symptoms, myringotomy and insertion of tympanostomy tubes may be considered. The most common complication is acute mastoiditis, but facial palsy, labyrinthitis, and in rare cases, even intracranial abscesses may also occur.


Epidemiological data refers to the US, unless otherwise specified.


Common pathogens [2]

Risk factors [1][8]

  • Passive cigarette smoke
  • Children who attend daycare centers
  • Formula feeding/bottle-feeding [9]
  • Pacifier use
  • Children who have more than one sibling or live in a crowded space
  • Male sex
  • Family or personal history of AOM
  • Anatomic abnormalities
  • Feeding in a supine position [10]

Older children and adults will most frequently report ear pain; in infants and nonverbal children symptoms can be nonspecific, and may be easily confused with other conditions.

General symptoms [8]

Typical presentation in infants [1][8]

Examination findings [8]


Tuning fork test

AOM is primarily a clinical diagnosis based on characteristic symptoms and otoscopic findings. Other causes of otalgia and hearing loss should be excluded (see “Differential diagnoses” section). Pneumatic otoscopy or tympanometry should be used to confirm the presence of an effusion. [2]

Diagnostic criteria for AOM in children [2][8]

Laboratory studies

Not routinely indicated; consider in severe infection or diagnostic uncertainty.

Imaging [16]

  • Rarely required unless there is clinical uncertainty and/or concerns of complications
  • Suspected intracranial complications: MRI brain and temporal bone
  • Suspected extracranial complications, e.g., mastoiditis: high-resolution CT temporal bone

Evaluation for effusion

  • Pneumatic otoscopy [17]
    • Description
      • A pneumatic bulb is attached to the otoscope to allow assessment of tympanic membrane mobility.
      • A seal is formed in the ear canal by the tip of the speculum, and air is forced in by pressing the bulb.
    • Indications: clinical uncertainty for AOM and to confirm the presence of middle ear effusion
    • Characteristic finding: hypomobility of the tympanic membrane [18]
  • Tympanometry [19]
    • Description: a probe is inserted into the ear to generate sound waves and measure pressure in the ear canal
    • Indications: confirmation of middle ear effusion [2][19]
    • Characteristic findings

The differential diagnoses listed here are not exhaustive.

Conservative management

Uncomplicated AOM is self-limiting in most children (∼ 80%) and the mainstay of treatment is pain relief and observation. [1][8]

Antibiotic treatment

  • Systemic antibiotic therapy in AOM is recommended to relieve symptoms and reduce the risk of complications in young infants and in severe infection. [2]
  • Topical antibiotics are not typically recommended for AOM with an intact tympanic membrane.
  • Treatment failure is common (due to drug resistance and viral coinfection); If initial treatment is unsuccessful, tympanocentesis should be considered to help guide further therapy.
  • The recommended duration of therapy depends on age and antibiotic choice.

Topical antibiotics are not effective in the treatment of acute otitis media with an intact tympanic membrane.


  • Children [2][8]
    • Symptoms do not improve after 48–72 hours.
    • Severe AOM
    • Signs of severe illness in children
    • Children ≤ 6 months [1][2]
    • Bilateral AOM in children < 24 months
    • AOM with otorrhea not due to otitis externa
    • All AOM in children with cochlear implants [20]
  • Adults: no clear guidance on indications exists; whether to start antibiotics for treatment should be guided by clinical symptoms and underlying risk factors. [1][8]

Not every case of otitis media requires treatment with antibiotics. [8]

Children with cochlear implants who develop AOM should always be treated with antibiotics.


Empiric antibiotic therapy for acute otitis media [2][21]
No antibiotic use in previous 30 days Antibiotic use in previous 30 days Penicillin allergy
Initial treatment
Treatment failure

H.influenzae and S.pneumoniae show limited sensitivity towards macrolides and trimethoprim/sulfamethoxazole; these antibiotics should only be used for patients with a proven history of type I hypersensitivity to penicillin. [8]

Surgical procedures

Special situations

Risk factors for complications

Complications are rare and are usually only seen in the following cases:

Intratemporal complications

Mastoiditis [8]

Bacterial labyrinthitis

Peripheral facial palsy [29]

Intracranial complications

We list the most important complications. The selection is not exhaustive.

  1. Lieberthal AS, Carroll AE, Chonmaitree T et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013; 131 (3). doi: 10.1542/peds.2012-3488 . | Open in Read by QxMD
  2. Kaur R, Morris M, Pichichero ME. Epidemiology of Acute Otitis Media in the Postpneumococcal Conjugate Vaccine Era. Official Journal of the American Society of Pediatrics. 2017; 140 (3): p.e20170181. doi: 10.1542/peds.2017-0181 . | Open in Read by QxMD
  3. Tong S, Amand C, Kieffer A, Kyaw MH. Trends in healthcare utilization and costs associated with acute otitis media in the United States during 2008–2014. BMC Health Serv Research. 2018; 18 (1). doi: 10.1186/s12913-018-3139-1 . | Open in Read by QxMD
  4. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  5. Ramakrishnan K, Sparks RA, Berryhill WE. Diagnosis and treatment of otitis media. Am Fam Physician. 2007; 76 (11): p.1650-1658.
  6. Bowatte G, Tham R, Allen K, et al. Breastfeeding and childhood acute otitis media: a systematic review and meta-analysis. Acta Paediatrica. 2015; 104 : p.85-95. doi: 10.1111/apa.13151 . | Open in Read by QxMD
  7. Avital A, Donchin M, Springer C, Cohen S, Danino E. Feeding young infants with their head in upright position reduces respiratory and ear morbidity. Nature. 2018; 8 (1). doi: 10.1038/s41598-018-24636-0 . | Open in Read by QxMD
  8. Orenstein WA, Perry RT, Halsey NA. The clinical significance of Measles: a review. J Infect Dis. 2004; 189 : p.4-16. doi: 10.1086/377712 . | Open in Read by QxMD
  9. Schlossberg D. Clinical Infectious Disease. Cambridge University Press ; 2015
  10. Gowin E, Wysocki J, Michalak M. Don’t forget how severe varicella can be—complications of varicella in children in a defined Polish population. Int J Infect Dis. 2013; 17 (7): p.e485-e489. doi: 10.1016/j.ijid.2012.11.024 . | Open in Read by QxMD
  11. Intakorn P, Sonsuwan N, Noknu S, et al. Haemophilus influenzae type b as an important cause of culture-positive acute otitis media in young children in Thailand: a tympanocentesis-based, multi-center, cross-sectional study. BMC Pediatr. 2014; 14 (1). doi: 10.1186/1471-2431-14-157 . | Open in Read by QxMD
  12. Shaikh N, Hoberman A, Rockette HE, Kurs-Lasky M. Development of an Algorithm for the Diagnosis of Otitis Media. Academic Pediatrics. 2012; 12 (3): p.214-218. doi: 10.1016/j.acap.2012.01.007 . | Open in Read by QxMD
  13. Bansal M. Essentials of Ear, Nose & Throat. JP Medical Ltd ; 2016
  14. Devaraja K. Myringitis: An update. J Otol. 2019; 14 (1): p.26-29. doi: 10.1016/j.joto.2018.11.003 . | Open in Read by QxMD
  15. Campbell WW, DeJong RN. DeJong's the Neurologic Examination. Lippincott Williams & Wilkins ; 2005
  16. Miller JM, Binnicker MJ, Campbell S, et al. A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology. Clin Infect Dis. 2018; 67 (6): p.e1-e94. doi: 10.1093/cid/ciy381 . | Open in Read by QxMD
  17. Trojanowska A, Drop A, Trojanowski P, Rosińska-Bogusiewicz K, Klatka J, Bobek-Billewicz B. External and middle ear diseases: radiological diagnosis based on clinical signs and symptoms. Insights Imaging. 2011; 3 (1): p.33-48. doi: 10.1007/s13244-011-0126-z . | Open in Read by QxMD
  18. Ponka D, Baddar F. Pneumatic otoscopy. Canadian Family Physician. 2013; 59 (9): p.962.
  19. Shaikh N, Hoberman A, Kaleida PH, et al. Otoscopic signs of otitis media. Pediatric Infectious Disease Journal. 2011; 30 (10): p.822-826. doi: 10.1097/INF.0b013e31822e6637 . | Open in Read by QxMD
  20. Onusko E. Tympanometry.. American Family Physician. 2004; 70 (9): p.1713-1720.
  21. Reactions Weekly. FDA taking action against unapproved ear drops. Reactions Weekly. 2015; 1560 (1): p.4-4. doi: 10.1007/s40278-015-3376-6 . | Open in Read by QxMD
  22. Rubin LG, Papsin B. Cochlear Implants in Children: Surgical Site Infections and Prevention and Treatment of Acute Otitis Media and Meningitis. Pediatrics. 2010; 126 (2): p.381-391. doi: 10.1542/peds.2010-1427 . | Open in Read by QxMD
  23. Gilbert, DN; Chambers, HF. Sanford Guide to Antimicrobial Therapy 2020. Antimicrobial Therapy, Inc ; 2020
  24. Andrews CJ, Rahul RK. Effect of myringotomy as an office procedure on the clinical course of acute otitis media: a retrospective study. Int J Otorhinolaryngol Head Neck Surg. 2017; 3 (3): p.646. doi: 10.18203/issn.2454-5929.ijohns20173040 . | Open in Read by QxMD
  25. Berger G. Nature of spontaneous tympanic membrane perforation in acute otitis media in children. The Journal of Laryngology & Otology. 1989; 103 (12): p.1150-1153. doi: 10.1017/s0022215100111247 . | Open in Read by QxMD
  26. Cameron P, Jelinek G, Kelly A-M, Murray L, Brown AFT. Textbook of Adult Emergency Medicine E-Book. Elsevier Health Sciences ; 2011
  27. Wolfson AB, Hendey GW, Ling LJ, Rosen CL, Schaider J, Sharieff GQ. Harwood-Nuss'Clinical Practice of Emergency Medicine. Wolters Kluwer ; 2009
  28. Polat S, Aksoy E, Serin GM, Yıldız E, Tanyeri H. Incidental diagnosis of mastoiditis on MRI. Eur Arch Otorhinolaryngol. 2011; 268 (8): p.1135-1138. doi: 10.1007/s00405-011-1506-1 . | Open in Read by QxMD
  29. Ferri FF. Ferri's Clinical Advisor 2015 E-Book. Elsevier Health Sciences ; 2014
  30. Schlossberg D. Infections of the Head and Neck. Springer Science & Business Media ; 2012
  31. Prasad S, Vishwas KV, Pedaprolu S, Kavyashree R. Facial Nerve Paralysis in Acute Suppurative Otitis Media-Management. Indian J Otolaryngol Head Neck Surg. 2017; 69 (1): p.58-61. doi: 10.1007/s12070-017-1051-3 . | Open in Read by QxMD
  32. Gupta S, Mends F, Hagiwara M, Fatterpekar G, Roehm PC. Imaging the Facial Nerve: A Contemporary Review. Radiol Res Pract. 2013; 2013 : p.1-14. doi: 10.1155/2013/248039 . | Open in Read by QxMD
  33. Murthy JMK, Saxena A. Bell′s palsy: Treatment guidelines. Ann Indian Acad Neurol. 2011; 14 (5): p.70. doi: 10.4103/0972-2327.83092 . | Open in Read by QxMD
  34. Wald ER. Acute mastoiditis in children: Treatment and prevention. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. updated: December 20, 2016. Accessed: March 23, 2017.
  35. Devan PP. Mastoiditis. In: Meyers AD, Mastoiditis. New York, NY: WebMD. Updated: January 9, 2017. Accessed: February 5, 2018.
  36. Boston ME. Labyrinthitis. In: Egan RA, Labyrinthitis. New York, NY: WebMD. Updated: January 23, 2017. Accessed: February 5, 2018.
  37. Klein JO, Pelton S. Acute otitis media in children: Epidemiology, microbiology, clinical manifestations, and complications. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. updated: September 29, 2016. Accessed: February 15, 2017.
  38. Donaldson JD. Acute Otitis Media. Acute Otitis Media. New York, NY: WebMD. Updated: October 5, 2016. Accessed: February 15, 2017.
  39. Huang LJ. Dehydration. In: Corden TE, Dehydration. New York, NY: WebMD. Updated: November 27, 2016. Accessed: April 12, 2017.
  40. Zhang Y, Xu M, Zhang J, Zeng L, Wang Y, Zheng QY. Risk Factors for Chronic and Recurrent Otitis Media–A Meta-Analysis. PLoS One. 2014; 9 (1). doi: 10.1371/journal.pone.0086397 . | Open in Read by QxMD
  41. Klein JO, Pelton S. Acute otitis media in children: Treatment. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. updated: January 24, 2017. Accessed: February 15, 2017.
  42. Wald ER. Acute Otitis Media in Children: Diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. updated: October 13, 2017. Accessed: February 5, 2018.
  43. NeuroLogic Exam. . Accessed: June 23, 2020.
  44. Harmes KM, Blackwood RA, Burrows HL, Cooke JM, Harrison RV, Passamani PP. Otitis media: diagnosis and treatment.. Am Fam Physician. 2013; 88 (7): p.435-40.
  45. Mathias B, Mira JC, Larson SD. Pediatric sepsis. Curr Opin Pediatr. 2016; 28 (3): p.380-387. doi: 10.1097/mop.0000000000000337 . | Open in Read by QxMD