Acute otitis media

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Acute otitis media often follows an upper respiratory infection. Ear pain, disturbed sleep and reduced hearing may develop with fever, irritability or poor feeding. In a young child these features are nonspecific, so the examination must establish middle-ear inflammation and also assess the child as a whole. A visibly red drum in a crying child is insufficient evidence by itself. Bulging, an opaque inflamed drum and a compatible acute history give a more coherent diagnosis.

The management decision balances symptom burden, likelihood of antibiotic benefit and risk of deterioration. Antibiotics do not replace analgesia and often make only a modest difference to uncomplicated childhood illness. A careful explanation of the expected course makes observation an active plan: the family knows how to give pain relief, what improvement should look like and when to return. NICE NG91 supplies the national antimicrobial framework for patients under 18; adult regimens are drawn from current local NHS guidance.

Key points

Acute otitis media is an acute inflammatory illness of the middle ear, usually associated with fluid behind the eardrum.
A bulging inflamed tympanic membrane supports the diagnosis more strongly than redness alone.
Most children improve within about three days, although symptoms can continue for a week.
Treat pain properly whether or not an antibiotic is prescribed.
For many otherwise well children, no antibiotic or a back-up prescription is appropriate.
In children and young people under eighteen, otorrhoea at any age and bilateral disease below two years identify groups more likely to benefit from antibiotics.
Those higher-benefit groups still need an individual choice among observation, back-up and immediate treatment under NICE guidance.
Persistent hearing difficulty after the acute illness may reflect effusion and needs appropriate follow-up.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Respiratory infection and middle-ear ventilation

A viral respiratory illness can impair Eustachian tube function and accompany bacterial infection within middle-ear fluid. Clinical appearance usually cannot identify the organism or reliably separate viral from bacterial contribution.

Childhood susceptibility

Young children have anatomical and functional factors that favour middle-ear fluid and recurrent episodes. Exposure to respiratory infections and individual craniofacial or immune factors influence the overall pattern of disease.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Inflammatory pressure
Fluid and inflammatory exudate accumulate in an enclosed middle-ear space. Drum tension contributes to pain, while reduced membrane and ossicular movement produces a temporary conductive hearing deficit.
2
Spontaneous perforation
Pressure can lead to a hole in the tympanic membrane and purulent discharge into the canal. Pain may improve as pressure falls, but otorrhoea changes antibiotic and topical analgesic decisions.
3
Residual effusion
The acute inflammatory illness can settle before normal aeration returns. Continuing muffled hearing after fever and pain resolve does not alone establish persistent bacterial infection or justify another antibiotic course.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Establish the acute course

Ask when pain started, whether a respiratory illness preceded it, how sleep and feeding are affected and whether discharge began after a change in pain. Record previous episodes and recent antibiotics.

Examine both ears

Assess the canal before the drum and compare sides. Note bulging, opacity, inflammation, visible fluid, perforation and discharge, rather than using the single description red ear.

Decide whether the patient is well

Check age-appropriate observations, interaction, hydration and perfusion. Assess the mastoid and neurological symptoms when the history suggests more than a local self-limiting illness.

Identify factors altering management

Ask about immune compromise, significant comorbidity, craniofacial conditions, cochlear implants and grommets. A surgically altered ear or vulnerable child may require a specialist pathway instead of routine uncomplicated AOM advice.

Red flags requiring action

A child who is drowsy, poorly perfused, dehydrated or difficult to rouse needs urgent assessment of systemic illness irrespective of the ear findings.
Swelling or fluctuance behind the ear, loss of the postauricular crease or outward displacement of the pinna suggests mastoid involvement.
Persistent vomiting, severe headache, diplopia, new imbalance or facial weakness may indicate extension beyond a simple middle-ear infection.
A young infant with fever needs an age-appropriate fever and serious-infection assessment rather than reassurance from an apparent ear diagnosis.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Clinical examination without routine blood testsFirst step
Why
Confirm the likely site and severity of uncomplicated illness.
Interpretation and limitations
A well child with straightforward acute otitis media usually needs no blood tests or imaging. Tests should address a specific concern rather than compensate for an incomplete ear examination.
02
Culture of ear discharge when indicated
Why
Investigate recurrent, resistant or otherwise complicated discharge.
Interpretation and limitations
An accessible specimen may help when treatment fails or unusual infection is suspected. Routine swabbing of every uncomplicated first episode is unnecessary, and a canal contaminant must be interpreted clinically.
03
Hospital blood tests and cultures
Why
Assess systemic infection and guide inpatient treatment.
Interpretation and limitations
An unwell child may need FBC, CRP and blood cultures under the paediatric pathway. Obtain these promptly while avoiding a delay to time-critical antibiotics or resuscitation.
04
Hearing assessment or specialist imaging
Why
Resolve persisting hearing concerns or suspected anatomical complications.
Interpretation and limitations
Audiology is appropriate when hearing or communication concerns remain after acute recovery. CT or MRI is reserved for suspected mastoid or intracranial complications in discussion with specialist teams.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Otitis externa

Marked canal tenderness, swelling and pain on tragal or pinna movement favour a canal origin. Discharge alone does not establish middle-ear infection, particularly when the drum has not been visualised.

Otitis media with effusion

Fluid without an acute inflammatory syndrome causes hearing difficulty and sometimes discomfort. The management pathway focuses on hearing and daily impact rather than routine antimicrobial treatment.

Referred otalgia

A normal ear examination should prompt assessment of dental, throat and jaw causes. Persistent unilateral pain in an adult also requires attention to possible head and neck pathology.

Complicated middle-ear disease

Cholesteatoma, mastoiditis or another destructive process may present with discharge. A chronic history, concerning drum pocket, postauricular findings or neurological symptoms changes referral urgency.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Otherwise well childRelieve pain and plan observationFirst stepUncomplicated disease has no immediate-treatment or hospital referral features.

1Give regular age- and weight-appropriate paracetamol or ibuprofen and explain how the family should administer it.
2Discuss no antibiotic or a back-up prescription according to the examination, symptom course and family circumstances.
3If a back-up is issued, explain use when symptoms fail to start improving within three days or worsen significantly at any time.
4Provide return instructions for systemic deterioration or complications, and reassess if symptoms persist rather than repeatedly extending observation.

02Antibiotic decisionMatch benefit to the individual patientOtorrhoea, young age with bilateral disease or systemic risk alters expected benefit.

1For otorrhoea at any age or bilateral AOM below two years, discuss the greater potential benefit and choose no, back-up or immediate antibiotics under NICE NG91.
2Give immediate antibiotics when the child is systemically very unwell, has signs of a more serious illness or is at high risk of complications.
3AlternativeUse the recommended age or weight regimen and check allergy, formulation, adherence and recent prescribing before selecting an alternative.
4If symptoms worsen after two to three days of first-choice treatment, reassess the diagnosis and complications before using the NICE second-choice pathway.

03Failure or complicationReassess and escalate promptlyEscalationPain or fever persists unexpectedly or concerning local or neurological signs emerge.

1Repeat the general and ear examination, checking hydration, the mastoid, facial movement and symptoms suggesting intracranial spread.
2Arrange hospital referral for severe systemic illness or acute complications instead of changing community treatment in isolation.
3In a child with grommets and uncomplicated discharge, follow the non-ototoxic topical treatment pathway rather than assuming every episode needs oral antibiotics.
4After the acute phase, investigate persistent hearing problems, recurrent discharge or a perforation that does not heal.

Key medicines and prescribing safety2 treatments · regimens, roles and cautions

First-choice oral antibiotic for susceptible uncomplicated acute otitis media when the clinical decision favours antimicrobial treatment.

Amoxicillin when an antibiotic is indicated

The NHS Lothian adult AOM pathway uses 500 mg orally every eight hours for five days. NICE NG91 under-18 dosing is 125 mg three times daily at 1–11 months, 250 mg three times daily at 1–4 years, and 500 mg three times daily at 5–17 years, for five to seven days.

Check penicillin allergy and previous severe beta-lactam reactions, renal function where relevant and interactions such as methotrexate. Paediatric age bands assume average size: use weight, severity and a suitable liquid formulation when needed. Review worsening symptoms, significant rash or severe diarrhoea promptly; do not extrapolate this short oral course to mastoiditis.

Additional local pain relief for a suitable intact eardrum; NICE recommends considering it when no immediate oral antibiotic is supplied.

Phenazone 40 mg/g with lidocaine 10 mg/g ear drops

Otigo: instil four drops into the affected ear two or three times daily for up to seven days. The product dose applies to adults and children; review sooner if deterioration occurs and stop if discharge develops.

Do not use with perforation, myringotomy, grommets or otorrhoea, and check for ingredient allergy. Exercise caution with susceptibility to methaemoglobinaemia, including infants under three months, haemoglobinopathies or G6PD deficiency. It does not treat invasive infection or replace systemic analgesia.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Perforation and persistent discharge

Many acute perforations heal as infection resolves, but persistent drainage or a non-healing defect requires reassessment. Document hearing concerns and avoid preparations unsuitable for an open middle ear.

Hearing and communication effects

Residual effusion can affect listening, classroom access and speech perception. Recurrent episodes or continuing functional concerns justify hearing assessment rather than repeated empirical antimicrobial prescriptions.

Mastoid and intracranial infection

Serious complications are uncommon but require rapid recognition. Their rarity supports selective prescribing in uncomplicated disease, while explicit safety-netting ensures that deterioration is not ignored.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Check whether pain, feeding and sleep are improving over the expected first few days.
Review the ear and the whole patient if symptoms worsen during an antibiotic course.
Ask families to seek urgent care for postauricular swelling, neurological symptoms or marked systemic deterioration.
Arrange hearing review when muffled hearing continues to affect communication after acute recovery.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Explain a back-up prescription clearly

A delayed prescription works only when the family knows the trigger for using it and the separate reasons to seek urgent review. Write both instructions explicitly.

Higher benefit does not mean automatic treatment

NICE allows a considered choice for a well child with otorrhoea or bilateral disease below two. Do not convert a subgroup finding into a universal instruction to prescribe immediately.

A discharging ear changes drop safety

Pain relief after perforation may be welcome, but the open membrane makes some analgesic or antibiotic preparations unsuitable. Recheck the product rather than continuing every existing drop.

Persistent symptoms need diagnostic thinking

Poor delivery, an incorrect dose, residual effusion and a different disease can all explain apparent failure. Escalating antibiotic spectrum is only one possible response after examination.

11Common pitfallsFrequent interpretation and management errors.

01
Redness alone is an unreliable basis for diagnosing acute middle-ear infection.
02
Do not withhold effective analgesia while waiting to see whether antibiotics help.
03
Antihistamines and decongestants do not provide useful routine treatment for acute otitis media.
04
A resolving fever does not excuse overlooking new mastoid or neurological signs.