Textbook of Urgent Care Medicine, Chapter 12, Otitis Media

INTRODUCTION

Acute otitis media (AOM) is defined as an infection or inflammation of the middle ear. AOM primarily occurs in childhood and is much less common in adults than in children. Fluid in the middle ear is accompanied by acute signs of illness and signs or symptoms of middle ear inflammation. Bulging of the tympanic membrane distinguishes AOM from a middle ear effusion (otitis media with effusion) and the normal tympanic membrane.

For children, diagnostic accuracy matters: AOM should not be diagnosed without middle-ear effusion. Current AAP criteria require moderate or severe bulging of the tympanic membrane, new otorrhea not caused by otitis externa, or mild bulging accompanied by recent ear pain or intense tympanic-membrane erythema.

Adult AOM remains much less common, and the pediatric evidence base should not be extrapolated without clinical judgment. Recurrent or persistent unilateral middle-ear disease in an adult warrants a lower threshold for specialty evaluation.

PRESENTATION

• Ear pain or pulling
• Fever
• Generally several days into a viral upper respiratory illness
• Otorrhea may occur when the tympanic membrane perforates; new otorrhea not due to otitis externa can itself satisfy diagnostic criteria for AOM.

TRIAGE PEARLS

• Drainage from the ear, including pus and blood
• Sudden decrease in hearing
• Pain, redness, or swelling behind or above ear
• Meningeal signs
• Multiple recurrent infections
• Toxic appearance, facial weakness, vertigo with neurologic findings, postauricular swelling with auricular protrusion, or concern for intracranial complication warrants emergency evaluation.
• Infants 8 to 60 days old with fever >=38.0 C require age-appropriate febrile-infant evaluation; a focal ear finding does not replace that risk assessment.

CARE ALGORITHM

The original two-page 2004-era algorithm was replaced because it began at age 2 months and relied on an “uncertain diagnosis” pathway that was removed from the 2013 AAP guideline.

HISTORY PEARLS

• Participation in day care, bottle-feeding, exposure to tobacco smoke and air pollution, and pacifier use
• Fever (possibly the only indicator in medical history for infants)
• Date of last episode or episodes of AOM
• Antibiotic use, especially amoxicillin, in the last 30 days
• Prior AOM treatment failure and any history of drug allergy, including the type and severity of reaction
• Immunization status, including age-appropriate pneumococcal and influenza vaccination
• Concurrent purulent conjunctivitis, which favors beta-lactamase coverage when antibiotics are prescribed

PHYSICAL EXAM PEARLS

• Assess the tympanic membrane for bulging, mobility, color, perforation, and otorrhea. Cerumen should be removed when necessary to obtain an adequate view.
• Pneumatic otoscopy is preferred when feasible to document middle-ear effusion.
• Rupture of the tympanic membrane
• Redness, swelling, or tenderness over mastoid air cells
• Meningeal signs
• Document postauricular swelling or tenderness, auricular protrusion/displacement, cranial nerve abnormalities, or toxic appearance because these findings raise concern for mastoiditis or another complication.

TESTING PEARLS

• Pneumatic otoscopy should be used to determine if a middle ear effusion is present.
• Tympanometry is useful when the diagnosis of middle-ear effusion remains uncertain after otoscopy; availability varies in urgent care.
• Routine laboratory testing and imaging are not needed for uncomplicated AOM.
• Tympanocentesis is reserved for selected severe, toxic, immunocompromised, or treatment-refractory cases and is generally performed by a specialist.

DIAGNOSIS PEARLS

• Definite AOM in children:
  • Moderate or severe bulging of the tympanic membrane, OR
  • New-onset otorrhea not caused by acute otitis externa, OR
  • Mild tympanic-membrane bulging plus ear pain beginning within 48 hours or intense tympanic-membrane erythema.
• Do not diagnose AOM in children without middle-ear effusion.
• Otitis media with effusion (OME): middle-ear effusion without the acute inflammatory signs and symptoms of AOM; decreased hearing may be present.
• Mastoiditis: postauricular tenderness, erythema, swelling, auricular protrusion/displacement, fever, or toxic appearance. Transfer for ED/ENT evaluation.
• Otorrhea through a spontaneous tympanic-membrane perforation may occur with AOM; fluid in the ear canal does not exclude AOM.

TREATMENT AND DISPOSITION PEARLS

• Pain control should be addressed in every patient, with acetaminophen or ibuprofen when appropriate.
• Children >=6 months with severe AOM - moderate/severe otalgia, otalgia for >=48 hours, or temperature >=39 C - should receive antibiotics.
• Children 6 to 23 months with nonsevere bilateral AOM should receive antibiotics. For nonsevere unilateral AOM in this age group, either antibiotics or observation with close follow-up is appropriate.
• Children >=24 months with nonsevere unilateral or bilateral AOM may receive antibiotics or observation with shared decision-making, provided follow-up is reliable and antibiotics can be started if symptoms worsen or fail to improve within 48 to 72 hours.
• First-line pediatric therapy when antibiotics are chosen: amoxicillin 80-90 mg/kg/day divided twice daily.
• Use high-dose amoxicillin-clavulanate (90 mg/kg/day of the amoxicillin component divided twice daily) when amoxicillin was used in the previous 30 days, concurrent purulent conjunctivitis is present, or recurrent AOM has been unresponsive to amoxicillin.
• Typical pediatric duration: 10 days for children <2 years or with severe symptoms; 7 days for ages 2-5 years; 5 days for children >6 years with nonsevere disease.
• Penicillin allergy should be characterized rather than treated as a single category. Cefdinir, cefuroxime, cefpodoxime, or ceftriaxone are options in many children with nonsevere penicillin allergy; severe immediate reactions require individualized selection based on allergy history and local guidance.
• If symptoms are not improving after 48-72 hours, reassess and confirm the diagnosis before changing therapy; exclude mastoiditis, otitis externa, OME, referred pain, or another diagnosis.
• Adults with clear AOM generally receive antibiotic treatment rather than pediatric-style observation; select agent and duration using local adult guidance, allergy history, recent antibiotic exposure, and comorbidities.
• Antihistamines, decongestants, and systemic or intranasal steroids are not recommended for routine treatment of AOM or OME in children.
• Topical analgesic drops may be considered only when the tympanic membrane is intact and an appropriate product is available; they are not a substitute for systemic analgesia.

TYMPANOSTOMY TUBES AND PERSISTENT EFFUSION

• For uncomplicated acute tympanostomy-tube otorrhea, prescribe topical antibiotic ear drops without oral antibiotics unless another indication for systemic therapy is present.
• Avoid ototoxic drops when the tympanic membrane is not intact unless specifically directed by an otolaryngologist; topical fluoroquinolone drops are commonly used.
• Recurrent AOM is commonly defined as 3 episodes in 6 months or 4 in 12 months (with at least 1 in the preceding 6 months). ENT referral is reasonable, but tympanostomy tubes should not be placed for recurrent AOM unless middle-ear effusion is present at the time of tube-candidacy assessment.
• OME without acute infection is usually observed. For children who are not otherwise at risk, watchful waiting for 3 months is recommended. Obtain an age-appropriate hearing test if OME persists for 3 months or longer, or at any duration in an at-risk child.
• Children with chronic OME who do not receive tubes should generally be reevaluated every 3-6 months until the effusion resolves, significant hearing loss is identified, or structural middle-ear disease is suspected.
• Do not use prophylactic antibiotics to prevent recurrent AOM.
• Encourage age-appropriate vaccination, breastfeeding when feasible, and avoidance of tobacco-smoke exposure.

MEDICOLEGAL PEARLS

• Document visualization of the tympanic membrane and the finding that supports AOM (bulging, effusion, or new otorrhea).
• Document the absence or presence of postauricular tenderness/swelling, meningeal signs, facial weakness, and tympanic-membrane perforation when clinically relevant.
• When observation is chosen, document caregiver agreement, reliable follow-up, and a specific plan to start antibiotics if the child worsens or fails to improve within 48-72 hours.

REFERENCES

1. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999. doi:10.1542/peds.2012-3488.
2. American Academy of Pediatrics. Red Book: 2024-2027 Report of the Committee on Infectious Diseases. Systems-Based Treatment Table: Acute Otitis Media. American Academy of Pediatrics; 2024.
3. Centers for Disease Control and Prevention. Outpatient Clinical Care for Pediatric Populations: Acute Otitis Media. Antibiotic Prescribing and Use. Updated online resource; accessed 2026.
4. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical Practice Guideline: Otitis Media with Effusion (Update). Otolaryngol Head Neck Surg. 2016;154(1 Suppl):S1-S41. doi:10.1177/0194599815623467.
5. Rosenfeld RM, Tunkel DE, Schwartz SR, et al. Clinical Practice Guideline: Tympanostomy Tubes in Children (Update). Otolaryngol Head Neck Surg. 2022;166(1 Suppl):S1-S55. doi:10.1177/01945998211065662.
6. Pantell RH, Roberts KB, Adams WG, et al. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics. 2021;148(2):e2021052228. doi:10.1542/peds.2021-052228.
7. National Institute for Health and Care Excellence. Otitis media (acute): antimicrobial prescribing. NICE guideline NG91. Updated 2022.