Otitis media (OM) is any inflammation of the middle ear (see the images below), without reference to

etiology or pathogenesis. It is very common in children.

Acute otitis media with purulent effusion behind a bulging tympanic membrane.

Chronic otitis media with a retraction pocket of the pars flaccida.

There are several subtypes of OM, as follows:

Acute otitis media (AOM)

Otitis media with effusion (OME)
Chronic suppurative otitis media
Adhesive otitis media

Signs and symptoms

AOM implies rapid onset of disease associated with one or more of the following symptoms:

Otalgia
Otorrhea
Headache
Fever
Irritability
Loss of appetite
Vomiting
Diarrhea
OME often follows an episode of AOM. Symptoms that may be indicative of OME include the
following:

Hearing loss
Tinnitus
Vertigo
Otalgia
Chronic suppurative otitis media is a persistent ear infection that results in tearing or perforation of the
eardrum.
Adhesive otitis media occurs when a thin retracted ear drum becomes sucked into the middle ear
space and stuck.
See Clinical Presentation for more detail.

Diagnosis
OME does not benefit from antibiotic treatment. Therefore, it is critical for clinicians to be able to
distinguish normal middle ear status from OME or AOM. Doing so will avoid unnecessary use of
antibiotics, which leads to increased adverse effects of medication and facilitates the development of
antimicrobial resistance.
Examination
Pneumatic otoscopy remains the standard examination technique for patients with suspected OM. In
addition to a carefully documented examination of the external ear and tympanic membrane (TM),
examining the entire head and neck region of patients with suspected OM is important.
Every examination should include an evaluation and description of the following four TM
characteristics:

Color A normal TM is a translucent pale gray; an opaque yellow or blue TM is consistent

with middle ear effusion (MEE)

Position In AOM, the TM is usually bulging; in OME, the TM is typically retracted or in the
neutral position

Mobility Impaired mobility is the most consistent finding in patients with OME

Perforation Single perforations are most common

Adjunctive screening techniques for OM include tympanometry, which measures changes in acoustic
impedance of the TM/middle ear system with air pressure changes in the external auditory canal, and
acoustic reflectometry, which measures reflected sound from the TM; the louder the reflected sound,
the greater the likelihood of an MEE.
See Workup for more detail.

Management
Most cases of AOM improve spontaneously. Cases that require treatment may be managed with
antibiotics and analgesics or with observation alone.
Guidelines from American Academy of Pediatrics
In February 2013, the American Academy of Pediatrics (AAP) and the American Academy of Family
Physicians released updated guidelines for the diagnosis and management of AOM, including
recurrent AOM, in children aged 6 months through 12 years. The recommendations offer more
rigorous diagnostic criteria to reduce unnecessary antibiotic use.
According to the guidelines, management of AOM should include an assessment of pain. Analgesics,
particularly acetaminophen and ibuprofen, should be used to treat pain whether antibiotic therapy is or
is not prescribed.
Recommendations for prescribing antibiotics include the following:

Antibiotics should be prescribed for bilateral or unilateral AOM in children aged at least 6
months with severe signs or symptoms (moderate or severe otalgia, otalgia for 48 hours or longer,
or temperature 39C or higher) and for nonsevere, bilateral AOM in children aged 6 to 23 months
On the basis of joint decision-making with the parents, unilateral, nonsevere AOM in children
aged 6-23 months or nonsevere AOM in older children may be managed either with antibiotics or
with close follow-up and withholding antibiotics unless the child worsens or does not improve within
48-72 hours of symptom onset
Amoxicillin is the antibiotic of choice unless the child received it within 30 days, has
concurrent purulent conjunctivitis, or is allergic to penicillin; in these cases, clinicians should
prescribe an antibiotic with additional beta-lactamase coverage