Clinical Practice Guidelines

Acute otitis media

  • Acute otitis media (AOM) is a common problem in early childhood; 2/3 of children have at least one episode by age 3, and 90% have at least one episode by school entry. Peak age prevalence is 6-18 months.


    • viral (25%)
    • Streptococcus pneumoniae (35%)
    • non-typable strains of Haemophilus influenzae (25%)
    • Moraxella catarrhalis (15%).


    Note: A child with otitis media can also have serious bacterial infection such as septicaemia or meningitis. If systemically unwell, consider coexistent causes of sepsis - do not accept otitis media as the sole diagnosis in a sick febrile young child without elimination of a more serious cause.(See febrile child guideline)


    fever, ear pain (irritability in pre-verbal children) +/- anorexia, vomiting, lethargy.


    • The usual middle ear landmarks (handle of malleus, incus, light reflex) are not well seen.
    • The tympanic membrane (TM) is dull and opaque, and may be bulging. The TM colour varies but is characteristically yellow-grey.
    • On pneumatic otoscopy TM mobility is reduced.
    • There may be associated signs of URTI, such as coryza, red tonsillopharynx, cough etc. The features suggest the infection is viral.
    • Many febrile or crying children have red TMs (just as they have red cheeks). A red TM alone is not acute otitis media.
    • It is not usually necessary to remove wax from the ear canals of febrile children


    • Perforation of the TM results in purulent otorrhoea, and usually relief of pain.
    • Febrile convulsions are commonly related to AOM.
    • Suppurative complications such as mastoiditis, suppurative labyrinthitis or intracranial infection (meningitis, extradural or subdural abscess, brain abscess) are very uncommon in our population.
    • Other potential complications include facial nerve palsy, lateral sinus thrombosis, and benign intracranial hypertension.

    Serous otitis media ("glue ear")

    Serous middle ear effusion commonly persists for several weeks or even months following an episode of AOM. This may be recurrent, even in the absence of identifiable episodes of AOM, and often causes conductive hearing loss. The long-term effects on language, literacy and cognitive development are unclear. Parental smoking is an important avoidable risk factor. The use of dummies should be limited to settling, as prolonged use has been shown to be associated with otitis media.


    Most cases of AOM in children resolve spontaneously. Antibiotics provide a small reduction in pain beyond 24 hours in only about 5% of children treated. The modest benefit must be weighed against the potential harms related to antibiotic use, both for the individual patient (adverse effects) and at a population level (resistance pressure). It has been shown that not using antibiotics for otitis media is acceptable to parents if the reasons are explained clearly.

    Pain is often the main symptom, so adequate analgesia is very important  Analgesia guideline. Paracetamol 20-30 mg/kg for 2-3 doses/day should be given if pain is significant. Short-term use of topical 2% lignocaine drops applied to the tympanic membrane has been shown to be effective for severe acute ear pain.  Decongestants, antihistamines and corticosteroids have not been shown to be effective in AOM.

    The following flow-diagram provides a recommended management scheme:

    Acute Otitis Media Flowchart

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