Acute Otitis Media

Acute otitis media (AOM) is an inflammatory process of the middle ear. The condition may occur at any age but mainly affects children, peaking between 6 and 18 months of age.[1] An estimated 30% of all antibiotics prescribed for children in the United States are prescribed for AOM.[2] Common specific symptoms include pain, the feeling of the ear being “blocked” (aural fullness), and partial temporary hearing loss. Vertigo is uncommon and should prompt investigation for alternative diagnoses. Nonspecific findings in young children include fever, irritability, reduced activity or expressivity, vomiting, and decreased appetite. An upper respiratory infection often precedes AOM, as resultant congestion can obstruct the eustachian tube, creating an accumulation of middle-ear secretions and a potential breeding ground for infections.[3] Spread of infection from the middle ear may result in mastoiditis, or, uncommonly, facial nerve paralysis or meningitis, as well as disease of other contiguous structures. Worsening of seasonal allergic rhinitis can predispose to AOM in adults.[1]

Risk Factors

AOM incidence peaks during the winter months.[4] Seasonal allergic rhinitis may also contribute.

The following factors are associated with risk for AOM:

Age < 10 years. Peak is between 6 months and 18 months.[1]

Pacifier use.[5] Bottle feeding, used in place of breastfeeding, may also increase risk, as noted below.

Recent URI.

Day care attendance.[3]

Tobacco smoke exposure.[6]

Air pollution.[7]

Hereditary factors.[5]

Low socioeconomic status.[8]


The most specific sign of acute otitis media is a bulging tympanic membrane.[9] Diagnosis requires an acute onset of ear pain or discomfort, erythema of the tympanic membrane, and a middle-ear effusion. Effusion can be demonstrated by a bulging and immobile tympanic membrane (or one with decreased mobility as demonstrated with pneumatic otoscopy), an air-fluid level, or otorrhea (if there is a perforation in the tympanic membrane).[10] If there is otorrhea and the ear canal is particularly tender, consider a diagnosis of acute otitis externa rather than otitis media. Tympanometry or acoustic reflectometry may substitute for pneumatic otoscopy when the presence of middle-ear effusion is uncertain.

An erythematous tympanic membrane alone should not be presumed to be due to AOM. Only 15% of such cases are caused by AOM.[11] Bulging, immobility of the tympanic membrane, an air-fluid level, or bubbles behind the TM must be present to make the diagnosis.

Bacterial culture of a middle ear aspirate is only indicated in the case of immunosuppression, severe illness (with AOM as the likely source), or refractory AOM.


Suggestions in the Nutritional Considerations section below should be considered early in the treatment of AOM; they may reduce the need for other treatments, which can often be difficult and taxing.

Decongestants and antihistamines have no proven benefit in AOM.[12]

The immediate treatment goal is to control pain. Several treatment options are available for otalgia.

NSAIDs and acetaminophen may improve symptoms.[13] Caution must be taken with acetaminophen in children as there is a narrower therapeutic window and therefore a higher risk of accidental overdose. Occasionally, opioids may be warranted for severe pain that is inadequately controlled with initial analgesic therapy.[14]

The American Academy of Pediatrics[7] and the American Academy of Family Physicians[12] make the following recommendations regarding use of antibiotics for AOM:

  • All patients under 6 months of age should receive antibiotics, even if the diagnosis of AOM is uncertain.
  • Patients aged 6 months to 2 years should receive antibiotics if the diagnosis is clear. If the diagnosis is uncertain, antibiotics should be given if otalgia is moderate to severe, lasts more than 48 hours, if AOM is bilateral, or if the patient’s temperature is ≥ 39°C. Otherwise, observation may be considered.
  • Patients older than 2 years with a definite diagnosis of AOM should start an antibiotic if otalgia is moderate to severe, or if fever reaches 39°C. Otherwise, observation may be considered.
  • Observation alone is permissible only if rapid initiation of antibiotics and follow-up can be guaranteed. Two-thirds of children will recover without the need for antibiotics.[15] Antibiotics should be started if no improvement occurs in 2-3 days.
  • Amoxicillin, 90 mg/kg divided into 2 doses for 10 days, is the first-line therapy.
  • For penicillin-allergic patients, cephalosporins may be used, provided patients did not develop hives or anaphylaxis with penicillin.[16] Macrolides or trimethoprim-sulfamethoxazole may also be used, but bacteria are often resistant to these medications.
  • Amoxicillin/clavulanate is used in certain regions with increased resistance or when broader coverage is desired.

Recurrent ear infections may warrant additional treatments, such as, tympanostomy with pressure equalization tube placement, and adenoidectomy (to improve Eustachian tube function).

Tympanostomy with pressure equalization tube placement is indicated for recurrent otitis media, or persistent, serous effusion causing hearing loss.

Adenoidectomy may benefit those who have recurrent AOM despite tympanostomy. Adenoidectomy may also reduce future AOM episodes when it occurs concomitantly with tympanostomy.[17]

Children suspected of having AOM should be evaluated by an otolaryngologist if they also have developmental delay, established hearing loss, or anatomic variants.[12]

Nutritional Considerations

Breastfeeding. Evidence suggests that breastfeeding for at least 6 months is protective against AOM.[8],[18]

Cow’s milk. Introducing cow’s milk before 4 months may increase risk of AOM.[19]

Allergies. Although most AOM follows viral infection, food and other environmental allergies can result in chronic otitis media in 35% to 40% of cases.[20] Diets that eliminate foods suspected of causing allergy have resulted in improvement in 86% of affected children, and most relapse when the offending foods are reintroduced.[10] These occurrences may be related to immunoglobulin G (IgG)-food antigen complexes, particularly those of cow’s milk protein.[21] A cohort study with 260 children found that those with cow’s milk allergy experienced significantly more recurrent otitis media.[22]

Nutritional status. Some children with otitis media have evidence of poor antioxidant status,[23] ,[24] suggesting that inadequate nutritional status may increase risk or prolong the condition. Specifically, low zinc, iron, vitamin A, and vitamin D levels are associated with AOM,[25] ,[26] and micronutrient supplementation in populations with poor nutrition has shown to be beneficial.[27] Antioxidant-rich and nutrient-dense fruits and berries may be protective.[28]


See Basic Diet Orders Chapter

Consider an elimination diet. For guidelines, see Anaphylaxis and Food Allergy chapter.

What to Tell the Family

Acute otitis media may be prevented in some cases by breastfeeding, avoiding crowded environments (such as day care), preventing exposure to tobacco smoke and (food) allergens, eliminating dairy products, refraining from the use of pacifiers, administering age-appropriate vaccinations,[29] and providing a diet with adequate micronutrients to support immune function. Antibiotic therapy is not always necessary, as 80% resolve spontaneously, and is contingent on severity, and signs and symptoms of bacterial infection. Repeated episodes of infection may require surgery.


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