Acute otitis media

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  • See also

    Febrile child 

    Key Points

    1. Do not accept otitis media as the sole diagnosis in a sick febrile young child without exclusion of more serious causes (see Febrile child)
    2. Diagnosis requires acute onset and an abnormal ear examination with signs of middle ear inflammation and middle ear effusion
    3. Avoid the routine use of antibiotic treatment for acute otitis media


    Acute Otitis Media (AOM) is a common problem in early childhood 

    • 75% of children have at least one episode by school age
    • Peak age prevalence is 6-18 months

    Causes of acute otitis media are often multifactorial. Exposure to cigarette smoke from household contacts is a known modifiable risk factor



    • Recent onset ear pain (irritability in pre-verbal children)
    • Fever
    • Loss of appetite
    • Vomiting
    • Lethargy 
    • Cochlear implant
    • Immunocompromise


    • Systemically unwell
    • Ear examination:
      • signs of acute inflammation of the tympanic membrane (TM): bulging, red, opaque TM
      • a red TM alone is not AOM. The most common cause is a viral upper respiratory tract infection (URTI)

      Otoscopic Images of Tympanic Membranes (TM):

      Normal Tympanic Membrane

      Normal Tympanic Membrane

      • TM is translucent
      • The handle of the malleus is vertical
      • No erythema

      Pink Tympanic Membrane

      Injected Tympanic Membrane

      • Pink/red TM
      • Often seen with fever, eustachian tube obstruction or viral URTI
      • TM is transparent (there is no middle ear effusion)
      • The handle of the malleus is well seen and is more horizontal


      Bulging and red tympanic membrane in AOM

      • Loss of the TM landmarks, especially the handle of the malleus
      • TM is opaque, may be red from inflammation or white from pus in the middle ear
      Otitis Media with Effusion (OME) glue ear

      Otitis Media with Effusion (OME) “glue ear”

      • TM is retracted with prominence of the handle of the malleus, which is also drawn in/more horizontal
      • TM may be bulging or have an air-fluid level behind the TM
      • Yellow/amber appearance is consistent with fluid
      • Light reflex on otoscopic examination

      Acute Otitis Media - Perforation

      Perforated Tympanic Membrane with otorrhoea

      Otitis Externa

      Otitis Externa

      • Ear is tender to examine
      • Skin of the external ear canal is swollen and there can be thin pus


      In Infants, especially <6 months old, the diagnosis of AOM and OME can be inaccurate. Other diagnoses should be fully considered (see Febrile child)

      Management may also differ for children from higher risk groups, such as those living in Aboriginal or Torres Strait Islander communities (see additional resources below)


      • There is no role for routine diagnostic investigation for AOM
      • Diagnostic imaging such as CT and MRI is usually only required in children with suspected intracranial complications


      • Most cases of AOM in children resolve spontaneously and antibiotics are not recommended
      • Treat pain with adequate and regular simple analgesia. See Acute pain management
      • As an adjunct, short-term use of topical analgesia eg 2% lignocaine, 1-2 drops applied to an intact tympanic membrane, may be effective for severe acute ear pain
      • Decongestants, antihistamines and corticosteroids are not effective in AOM

      Acute mastoiditis


      Tympanic membrane perforation

      • AOM with TM perforation is common and results in otorrhoea and frequently, relief of pain
      • Otorrhoea due to TM perforation should be distinguished from Otitis Externa

      Acute Mastoiditis (AM)
      Acute mastoiditis, although rare, is the most common suppurative complication of AOM and may be associated with intracranial complications

      • The diagnosis of AM is based on post auricular inflammatory signs (erythema, oedema, tenderness or fluctuance), a protruding auricle often with external auditory canal oedema and signs of AOM (see image below)
      • Requires prompt treatment with appropriate intravenous antibiotics (eg flucloxacillin plus 3rd generation cephalosporin)
      • Consult ENT as may require surgical treatment

      ENT involvement
      Acute mastoiditis

      Other complications

      • Other suppurative complications including intracranial spread of infection are rare
      • Facial nerve palsy secondary to AOM should be discussed with ENT
      • Long-term non suppurative complications include atelectasis of the TM and cholesteatoma

      Otitis Media with Effusion (OME)

      • OME, previously termed serous otitis or glue ear, is fluid in the middle ear without signs and symptoms of infection, other than transient hearing impairment
      • The presence of a middle ear effusion is not a diagnostic sign of AOM (an effusion may not resolve for up to 12 weeks following AOM)
      • Antibiotics and ENT referral are not routinely required for OME, as the majority of cases occur after an episode of AOM and resolve spontaneously with no long-term effects on language, literacy or cognitive development
      • Persistent effusion beyond 3 months should trigger a hearing assessment and ENT involvement/referral

      Consider consultation with local paediatric team when

      • Children who are systemically unwell
      • Neonates
      • Children with signs of acute mastoiditis or who have a cochlear implant should be discussed with ENT

      Consider transfer when

      Children requiring care beyond the level of comfort of the local hospital

      For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

      Consider discharge when

      No signs of complications

      Additional resources

      Otitis media guidelines for Aboriginal and Torres Strait Islander children

      Parent information

      Ear Infections and Glue Ear 


      Last Updated June 2021

  • Reference List

    1. Hoberman, A et al. Shortened antimicrobial treatment for acute otitis media in young children. New England Journal of Medicine.2016. 375 (25), p2446 – 2456
    2. Lieberthal, AS et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013.131 (3), p964 – 999. [Available from]
    3. Lueng, A et al. Acute Otitis Media in Children. Recent Patents on Inflammation & Allergy Drug Discovery. 2017. 11 (1), p32 – 40. [Available from]
    4. Pelton, S. Acute otitis media in children: Epidemiology, microbiology, clinical manifestations, and complications. Retrieved from (viewed 3 August 2019)
    5. Pelton, S. Acute otitis media in children: Treatment. Retrieved from (viewed 3 August 2019)
    6. Tahtinen, PA et al. Prognostic Factors for Treatment Failure in Acute Otitis Media. Pediatrics. 2017. 140 (3), p1 – 8. [Available from]
    7. Torzillo, P et al. Otitis media guidelines for Aboriginal and Torres Strait Islander children. 2017. Retrieved from (viewed May 2021)
    8. Wald, E. Acute otitis media in children: Diagnosis. Retrieved from (viewed 2 August 2019)

    Photos (in order of appearance)

    1. Normal Tympanic Membrane: Hawke Library. The Normal Tympanic Membrane. (viewed 15 August 2019)
    2. Injected Tympanic Membrane: University of Wisconsin School of Medicine and Public Health. Acute Otitis Media – Patient Evaluation. (viewed 15 August 2019)
    3. Bulging Tympanic Membrane: Hawke Library. Mastoiditis. (viewed 15 August 2019)
    4. Otitis media with effusion: Hawke Library. Mucoid Otitis Media. (viewed 15 August 2019)
    5. Perforated tympanic membrane: Hawke Library. Acute Otitis Media - perforation. (viewed 15 August 2019)
    6. Otitis Externa: Davis, S. Otitis Externa. (viewed 15 August 2019)
    7. Acute Mastoiditis: Welleschik, B. Mastoiditis with subperiosteal abscess. (viewed 15 August 2019)