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  • Clinician

Acute otitis media (Middle ear infection)


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 [8][1]

  • 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 gender
  • Family or personal history of AOM
  • Anatomic abnormalities
  • Feeding in a supine position [10]

Clinical features

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]

  • Irritability
  • Incessant crying
  • Refusal to feed (anorexia)
  • Repeatedly touching the affected ear
  • Fever and febrile seizures
  • Vomiting

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

Differential diagnoses

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 [21][2]
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]

  • Definition: inflammation of the mastoid air cells
  • Epidemiology: : most commonly occurs in children < 2 years [25]
  • Pathophysiology: infection spreads from the middle ear cavity into the mastoid, which is a closed bony compartment → collection of pus under tension and hyperemic resorption of the bony walls → destruction of the air cells (coalescent mastoiditis) → mastoid becomes a pus-filled cavity (empyema mastoid)
  • Clinical features
    • Recurrence of otalgia and fever after initial improvement
    • Symptoms persist for > 2 weeks
    • Tender and edematous mastoid
    • Ear displaced laterally and forward
    • In advanced stages, the retroauricular sulcus is obliterated and the ear can be pushed forward.
    • In chronic mastoiditis, there may be persistent otorrhea.
  • Diagnostics
    • Otoscopy
    • Initial investigation: CT scan of the temporal bone
      • Opacification of the mastoid air cells
      • Erosion of the air cell walls
      • Pus in the mastoid cavity (areas of enhancement on CT)
    • MRI brain and temporal bone [26]
      • Indicated in intracranial complications
      • Characteristic findings include increased fluid signal intensity in mastoid air cells.
    • X-ray of the mastoid [27][28]
      • Early stage: The air cells appear cloudy and indistinct.
      • Advanced stage: A cavity can be seen in the mastoid.
  • Treatment [21]

Bacterial labyrinthitis

Peripheral facial palsy [29]

Intracranial complications

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

  • 1. Ramakrishnan K, Sparks RA, Berryhill WE. Diagnosis and treatment of otitis media. Am Fam Physician. 2007; 76(11): pp. 1650–1658. url: http://www.aafp.org/afp/2007/1201/p1650.html.
  • 2. 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.
  • 3. Huang LJ. Dehydration. In: Corden TE. Dehydration. New York, NY: WebMD. http://emedicine.medscape.com/article/906999. Updated November 27, 2016. Accessed April 12, 2017.
  • 4. 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.
  • 5. Klein JO, Pelton S. Acute otitis media in children: Epidemiology, microbiology, clinical manifestations, and complications. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/acute-otitis-media-in-children-epidemiology-microbiology-clinical-manifestations-and-complications. Last updated September 29, 2016. Accessed February 15, 2017.
  • 6. Donaldson JD. Acute Otitis Media. In: Acute Otitis Media. New York, NY: WebMD. http://emedicine.medscape.com/article/859316-overview. Updated October 5, 2016. Accessed February 15, 2017.
  • 7. 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.
  • 8. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Philadelphia, PA: Elsevier Health Sciences; 2018.
  • 9. Bowatte G, Tham R, Allen K, et al. Breastfeeding and childhood acute otitis media: a systematic review and meta-analysis. Acta Paediatrica. 2015; 104: pp. 85–95. doi: 10.1111/apa.13151.
  • 10. 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.
  • 11. Shaikh N, Hoberman A, Rockette HE, Kurs-Lasky M. Development of an Algorithm for the Diagnosis of Otitis Media. Academic Pediatrics. 2012; 12(3): pp. 214–218. doi: 10.1016/j.acap.2012.01.007.
  • 12. Bansal M. Essentials of Ear, Nose & Throat. JP Medical Ltd; 2016.
  • 13. Devaraja K. Myringitis: An update. J Otol. 2019; 14(1): pp. 26–29. doi: 10.1016/j.joto.2018.11.003.
  • 14. Campbell WW, DeJong RN. DeJong's the Neurologic Examination. Lippincott Williams & Wilkins; 2005.
  • 15. 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. Clinical Infectious Diseases. 2018; 67(6): pp. e1–e94. doi: 10.1093/cid/ciy381.
  • 16. 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): pp. 33–48. doi: 10.1007/s13244-011-0126-z.
  • 17. Ponka D, Baddar F. Pneumatic otoscopy. Canadian Family Physician. 2013; 59(9): p. 962. pmid: 24029512.
  • 18. Shaikh N, Hoberman A, Kaleida PH, et al. Otoscopic signs of otitis media. Pediatric Infectious Disease Journal. 2011; 30(10): pp. 822–826. doi: 10.1097/INF.0b013e31822e6637.
  • 19. Onusko E. Tympanometry. American Family Physician. 2004; 70(9): pp. 1713–1720. pmid: 15554489.
  • 20. 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): pp. 381–391. doi: 10.1542/peds.2010-1427.
  • 21. Gilbert, DN; Chambers, HF. Sanford Guide to Antimicrobial Therapy 2020. Antimicrobial Therapy, Inc; 2020.
  • 22. 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.
  • 23. Berger G. Nature of spontaneous tympanic membrane perforation in acute otitis media in children. The Journal of Laryngology & Otology. 1989; 103(12): pp. 1150–1153. doi: 10.1017/s0022215100111247.
  • 24. Cameron P, Jelinek G, Kelly A-M, Murray L, Brown AFT. Textbook of Adult Emergency Medicine E-Book. Elsevier Health Sciences; 2011.
  • 25. Wolfson AB, Hendey GW, Ling LJ, Rosen CL, Schaider J, Sharieff GQ. Harwood-Nuss'Clinical Practice of Emergency Medicine. Philadelphia, PA: Wolters Kluwer; 2009.
  • 26. Polat S, Aksoy E, Serin GM, Yıldız E, Tanyeri H. Incidental diagnosis of mastoiditis on MRI. Eur Arch Otorhinolaryngol. 2011; 268(8): pp. 1135–1138. doi: 10.1007/s00405-011-1506-1.
  • 27. Ferri FF. Ferri's Clinical Advisor 2015 E-Book. Elsevier Health Sciences; 2014.
  • 28. Schlossberg D. Infections of the Head and Neck. Springer Science & Business Media; 2012.
  • 29. 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): pp. 58–61. doi: 10.1007/s12070-017-1051-3.
  • 30. Gupta S, Mends F, Hagiwara M, Fatterpekar G, Roehm PC. Imaging the Facial Nerve: A Contemporary Review. Radiol Res Pract. 2013; 2013: pp. 1–14. doi: 10.1155/2013/248039.
  • 31. Murthy JMK, Saxena A. Bell′s palsy: Treatment guidelines. Ann Indian Acad Neurol. 2011; 14(5): p. 70. doi: 10.4103/0972-2327.83092.
  • Mathias B, Mira JC, Larson SD. Pediatric sepsis. Curr Opin Pediatr. 2016; 28(3): pp. 380–387. doi: 10.1097/mop.0000000000000337.
  • 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.
  • Klein JO, Pelton S. Acute otitis media in children: Treatment. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/acute-otitis-media-in-children-treatment?source=search_result&search=acute%20otitis%20media&selectedTitle=1~150#H12. Last updated January 24, 2017. Accessed February 15, 2017.
  • Schlossberg D. Clinical Infectious Disease. Cambridge University Press; 2015.
  • Reactions Weekly. FDA taking action against unapproved ear drops. Reactions Weekly. 2015; 1560(1): pp. 4–4. doi: 10.1007/s40278-015-3376-6.
  • NeuroLogic Exam. https://neurologicexam.med.utah.edu/adult/html/home_exam.html. Accessed June 23, 2020.
  • Orenstein WA, Perry RT, Halsey NA. The clinical significance of Measles: a review. J Infect Dis. 2004; 189: pp. 4–16. doi: 10.1086/377712.
  • 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.
  • 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): pp. e485–e489. doi: 10.1016/j.ijid.2012.11.024.
  • Wald ER. Acute mastoiditis in children: Treatment and prevention. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/acute-mastoiditis-in-children-treatment-and-prevention. Last updated December 20, 2016. Accessed March 23, 2017.
  • Wald ER. Acute Otitis Media in Children: Diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/acute-otitis-media-in-children-diagnosis. Last updated October 13, 2017. Accessed February 5, 2018.
  • Devan PP. Mastoiditis. In: Meyers AD. Mastoiditis. New York, NY: WebMD. https://emedicine.medscape.com/article/2056657. Updated January 9, 2017. Accessed February 5, 2018.
  • Boston ME. Labyrinthitis. In: Egan RA. Labyrinthitis. New York, NY: WebMD. https://emedicine.medscape.com/article/856215. Updated January 23, 2017. Accessed February 5, 2018.
  • Harmes KM, Blackwood RA, Burrows HL, Cooke JM, Harrison RV, Passamani PP. Otitis media: diagnosis and treatment. Am Fam Physician. 2013; 88(7): pp. 435–40. pmid: 24134083.
last updated 09/17/2020
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