Overview
Acute Otitis Media
Quick Reference
Critical Alerts
- Diagnosis requires visualization of tympanic membrane: Bulging TM with effusion
- Not all ear pain is otitis media: Consider otitis externa, trauma, referred pain
- Observation option for mild cases: In children >2 years with unilateral AOM
- Mastoiditis is a complication requiring urgent intervention: Post-auricular swelling, tenderness
- Amoxicillin is first-line: High-dose for resistant organisms
- Pain management is essential: Often undertreated
Diagnostic Criteria (AAP)
All 3 required:
- Acute onset of symptoms (otalgia, fever, irritability)
- Middle ear effusion (bulging TM, decreased mobility, air-fluid level)
- Signs of inflammation (erythema, otalgia, or fever)
Emergency Treatments
| Population | Treatment |
|---|---|
| <2 years or severe symptoms | Amoxicillin 80-90 mg/kg/day ÷ BID × 10 days |
| > years, mild, unilateral | Observation option (analgesics, follow-up) |
| Treatment failure (48-72h) | Amoxicillin-clavulanate 90 mg/kg/day ÷ BID × 10 days |
| Penicillin allergy | Cefdinir, cefuroxime, or azithromycin |
| Pain control | Ibuprofen, acetaminophen, topical drops |
Definition
Overview
Acute otitis media (AOM) is a bacterial or viral infection of the middle ear, characterized by acute onset of symptoms and middle ear effusion with signs of inflammation. It is one of the most common pediatric infections and a leading cause of antibiotic prescriptions. Most cases are self-limited, but antibiotics are indicated for young children and severe presentations.
Classification
By Presentation:
| Type | Definition |
|---|---|
| Acute otitis media (AOM) | Acute infection with effusion and inflammation |
| Otitis media with effusion (OME) | Effusion without acute infection (not AOM) |
| Recurrent AOM | ≥3 episodes in 6 months OR ≥4 in 12 months |
| Chronic suppurative OM | Persistent TM perforation with drainage > weeks |
Epidemiology
- Peak age: 6-24 months
- By age 3: 80% of children have had ≥1 AOM episode
- Seasonality: Fall and winter (URI season)
- Common in daycare: Increased exposure
Etiology
Bacterial Causes (~70% of AOM):
| Organism | Frequency |
|---|---|
| Streptococcus pneumoniae | 25-50% |
| Haemophilus influenzae (non-typeable) | 15-30% |
| Moraxella catarrhalis | 10-20% |
| Group A Streptococcus | 2-5% |
Viral Causes (~30% are viral or mixed):
- RSV, influenza, rhinovirus, adenovirus
Risk Factors:
| Factor | Mechanism |
|---|---|
| URI | Eustachian tube dysfunction |
| Daycare attendance | Exposure to pathogens |
| Bottle feeding (lying down) | Reflux into middle ear |
| Pacifier use | Increases URI risk |
| Secondhand smoke | Mucosal irritation |
| Craniofacial abnormalities | Eustachian tube dysfunction |
Pathophysiology
Mechanism
- URI/Nasopharyngeal infection: Bacteria/viruses in nasopharynx
- Eustachian tube dysfunction: Inflammation, edema, obstruction
- Negative middle ear pressure: Drawing secretions into middle ear
- Middle ear effusion: Fluid accumulation
- Bacterial overgrowth: Infection and inflammation of middle ear
Why Children Are More Susceptible
- Shorter, more horizontal Eustachian tube
- Immature immune system
- Adenoid hypertrophy
- Frequent URIs
Clinical Presentation
Symptoms
| Symptom | Notes |
|---|---|
| Otalgia (ear pain) | Most reliable symptom in verbal children |
| Ear tugging/rubbing | In infants/toddlers |
| Fever | Variable, may be absent |
| Irritability | Non-specific in young children |
| Decreased hearing | Due to effusion |
| Otorrhea | If TM perforated |
| URI symptoms | Often precedes AOM |
| Sleep disturbance | Pain worsens when lying down |
History
Key Questions:
Physical Examination
Otoscopy (Key Diagnostic Tool):
| Finding | Significance |
|---|---|
| Bulging tympanic membrane | Most specific for AOM |
| Erythema | Inflammation (less specific alone) |
| Decreased/absent mobility (pneumatic otoscopy) | Effusion |
| Purulent effusion (yellow/white) | Infection |
| Air-fluid level | Effusion |
| TM perforation with otorrhea | Chronic or severe |
| Opacified TM | Effusion |
Other Exam Findings:
| Finding | Significance |
|---|---|
| Fever | Variable |
| Cervical lymphadenopathy | Reactive |
| Mastoid tenderness, post-auricular swelling | MASTOIDITIS—urgent referral |
Ear pain or tugging?
Common presentation.
Fever?
Common presentation.
Recent URI?
Common presentation.
History of prior ear infections?
Common presentation.
Antibiotic exposure in past 30 days?
Common presentation.
Allergies to antibiotics?
Common presentation.
Daycare attendance?
Common presentation.
Immunization status?
Common presentation.
Red Flags
Complications of AOM
| Finding | Concern | Action |
|---|---|---|
| Post-auricular swelling, tenderness | Mastoiditis | CT, IV antibiotics, ENT |
| Facial nerve palsy | Extension of infection | CT, ENT |
| Severe headache, vomiting | Intracranial extension (meningitis, abscess) | CT, LP, hospitalization |
| High fever with toxic appearance | Sepsis, bacteremia | Workup, IV antibiotics |
| Persistent otorrhea > weeks | Chronic suppurative OM | ENT referral |
Differential Diagnosis
Other Causes of Ear Pain
| Diagnosis | Features |
|---|---|
| Otitis externa | Canal erythema/edema, pain with tragal pressure, normal TM |
| Otitis media with effusion (OME) | Effusion without acute inflammation (not AOM) |
| Foreign body | Visible in canal |
| Referred pain (dental, TMJ) | Normal ear exam |
| Mastoiditis | Post-auricular swelling, tenderness |
| Cerumen impaction | Visible wax, often asymptomatic |
| Barotrauma | History of pressure change (flying, diving) |
Diagnostic Approach
Clinical Diagnosis
- AOM is a clinical diagnosis based on otoscopy
- No labs or imaging needed for uncomplicated cases
Elements of Diagnosis (AAP)
- Acute onset (<48 hours)
- Middle ear effusion (bulging TM, decreased mobility, otorrhea)
- Signs/symptoms of inflammation (erythema, otalgia, fever)
Pneumatic Otoscopy
- Gentle puff of air → Assess TM mobility
- Decreased mobility = Effusion
- Gold standard for AOM diagnosis
Tympanometry
- Objective measure of TM mobility
- Flat tracing (Type B) = Effusion
- Rarely used in ED
Imaging
- Not indicated for uncomplicated AOM
- CT temporal bone: For suspected mastoiditis or intracranial complication
Treatment
Principles
- Pain management: Priority for all patients
- Antibiotics for indicated populations: <2 years, severe, bilateral
- Observation option: For mild cases in older children
- Safety-net prescription: If observation chosen
Antibiotic Decision (AAP Guidelines)
Immediate Antibiotics:
| Criteria | Indication |
|---|---|
| Age <6 months | Always treat |
| Age 6 months-2 years | Treat if severe OR bilateral |
| Age ≥2 years + severe | Treat |
| Age ≥2 years + bilateral | Treat |
| Otorrhea (with AOM) | Treat |
| Immunocompromised | Treat |
Observation Option (Safety-Net Prescription):
| Criteria | Indication |
|---|---|
| Age ≥2 years | AND |
| Mild symptoms (mild otalgia <48h, temp <39°C) | AND |
| Unilateral | AND |
| Reliable follow-up | Then observation × 48-72h is reasonable |
First-Line Antibiotic: Amoxicillin
High-Dose Amoxicillin:
| Population | Dose | Duration |
|---|---|---|
| Standard | 80-90 mg/kg/day ÷ BID | 10 days (<2 years) or 5-7 days (≥2 years) |
Why High-Dose?
- Overcomes intermediate penicillin-resistant S. pneumoniae (PRSP)
Second-Line Antibiotics
Amoxicillin-Clavulanate (If Treatment Failure):
| Indication | Dose |
|---|---|
| No improvement in 48-72h on amoxicillin | 90 mg/kg/day amoxicillin component ÷ BID × 10 days |
| Recent amoxicillin use (<30 days) | Same |
Penicillin Allergy:
| Severity | Alternative |
|---|---|
| Non-anaphylactic | Cefdinir, cefuroxime, cefpodoxime |
| Anaphylactic | Azithromycin 10 mg/kg day 1 → 5 mg/kg days 2-5 |
Pain Management
Essential—Often Undertreated:
| Agent | Dose |
|---|---|
| Ibuprofen | 10 mg/kg q6-8h |
| Acetaminophen | 15 mg/kg q4-6h |
| Topical benzocaine/antipyrine drops | If TM intact |
TM Perforation with Otorrhea
- Topical fluoroquinolone (ofloxacin, ciprofloxacin otic) is an option
- Avoid ototoxic drops (aminoglycosides) if TM perforated
Disposition
Discharge Criteria
- Uncomplicated AOM
- Pain controlled
- Parents educated on warning signs
- Follow-up arranged (if observation)
Admission Criteria
- Mastoiditis
- Intracranial complication suspected
- Toxic appearance / Sepsis
- Unable to tolerate oral medications
- Immunocompromised with severe infection
Referral
| Indication | Referral |
|---|---|
| Recurrent AOM (≥3 in 6 months) | ENT for possible tubes |
| Chronic suppurative OM | ENT |
| Mastoiditis | ENT (emergent) |
Follow-Up
| Situation | Follow-Up |
|---|---|
| Observation chosen | 48-72 hours if no improvement |
| Antibiotics started | PCP in 2-3 days if not improving |
| Recurrent AOM | ENT referral |
Patient Education
Condition Explanation
- "Your child has an ear infection, which means there's fluid and infection behind the eardrum."
- "This usually clears up on its own or with antibiotics."
- "Pain control is very important."
Home Care
- Give pain medication regularly (not just PRN)
- Complete full course of antibiotics if prescribed
- Warm compress to ear for comfort
- Elevate head slightly when sleeping
Warning Signs to Return
- Fever not improving after 48-72 hours on antibiotics
- Swelling or redness behind the ear
- Severe headache or neck stiffness
- Worsening pain or irritability
- Facial droop
Special Populations
Infants <6 Months
- Always treat with antibiotics
- Higher risk of complications
- Consider admission if very young or ill-appearing
Recurrent AOM
- ≥3 episodes in 6 months or ≥4 in 12 months
- ENT referral for tympanostomy tubes
- Consider prophylaxis (controversial)
Adults with AOM
- Less common than children
- Same pathogens
- Evaluate for underlying issues (immunodeficiency, nasopharyngeal mass)
- Treat with amoxicillin-clavulanate or fluoroquinolone
Immunocompromised
- Lower threshold for treatment
- Broader antibiotic coverage
- Low threshold for imaging if complications suspected
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| Otoscopy documented | 100% | Diagnostic requirement |
| High-dose amoxicillin as first-line | >0% | Guideline adherence |
| Pain medication prescribed or discussed | 100% | Undertreated |
| Observation option offered when appropriate | >0% | Antibiotic stewardship |
Documentation Requirements
- Otoscopic findings (TM appearance, mobility, effusion)
- Laterality (unilateral vs bilateral)
- Severity
- Treatment decision rationale
- Follow-up plan
Key Clinical Pearls
Diagnostic Pearls
- Bulging TM is most specific: Erythema alone is not enough
- Crying can cause TM erythema: Look for bulging, effusion
- Pneumatic otoscopy improves accuracy: Assess mobility
- Not all ear pain is AOM: Check canal (otitis externa)
- OME is not AOM: Effusion without acute inflammation
- Fever is variable: Absence does not rule out AOM
Treatment Pearls
- High-dose amoxicillin is first-line: 80-90 mg/kg/day
- Pain control is essential: Don't forget!
- Observation is valid for mild cases: In children ≥2 years
- Amoxicillin-clavulanate for treatment failure: Or recent amoxicillin use
- Topical fluoroquinolone if TM perforated: Avoid aminoglycosides
- Duration shorter in older children: 5-7 days if ≥2 years
Disposition Pearls
- Most can go home: With antibiotics or observation
- Mastoiditis is a surgical emergency: ENT, IV antibiotics, CT
- Recurrent AOM needs ENT referral: Consider tubes
- Follow-up important for observation: 48-72 hours
References
- Lieberthal AS, et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013;131(3):e964-e999.
- Rosenfeld RM, et al. Clinical Practice Guideline: Otitis Media with Effusion. Otolaryngol Head Neck Surg. 2016;154(1 Suppl):S1-S41.
- American Academy of Family Physicians. Diagnosis and Management of Acute Otitis Media. Am Fam Physician. 2017;96(7):426-429.
- Pichichero ME. Acute otitis media: Part I. Improving diagnostic accuracy. Am Fam Physician. 2000;61(7):2051-2056.
- Coker TR, et al. Diagnosis, Microbial Epidemiology, and Antibiotic Treatment of Acute Otitis Media in Children. JAMA. 2010;304(19):2161-2169.
- Hoberman A, et al. Treatment of Acute Otitis Media in Children under 2 Years of Age. N Engl J Med. 2011;364(2):105-115.
- AAP Section on Infectious Diseases. Red Book: 2021-2024 Report of the Committee on Infectious Diseases.
- UpToDate. Acute otitis media in children: Clinical manifestations and diagnosis. 2024.