Otitis media is a general term used to describe inflammation of the middle ear which may be caused by an acute infection.
The symptoms are usually nonspecific and include otalgia (pulling of ear in an infant), irritability, otorrhea with or without fever.
Symptoms of upper respiratory tract infection may also be present

Principles of Therapy

  • Depending on the diagnostic certainty, patient’s age, illness severity & assurance of follow-up, selected patients may be treated with observation without antibiotic therapy
    • Placebo-controlled trials have shown that most patients improve without adverse consequences without antimicrobial therapy
  • An antibiotic prescription may be given to the guardian if patient’s symptoms worsen within 2-3 days or anytime during the observation period
Patients Who Should be Treated Initially with Antibiotics
  • <6 months old, with acute otitis media, regardless if with mild, moderate or severe symptoms
  • ≥6 months old, with either unilateral or bilateral acute otitis media (AOM), presenting with severe illness
    • Severe illness is considered if otalgia is moderate to severe for >48 hours or if fever ≥39°C (≥102.2°F)
  • ≥6 months old, with acute otitis media (AOM), with otorrhea
  • 6-23 months old, with bilateral acute otitis media (AOM), presenting with mild otalgia for <48 hours & fever <39°C, no otorrhea
  • 6-23 months old, with unilateral acute otitis media (AOM), & presenting with non-severe illness (mild otalgia for <48 hours & fever <39°C), no otorrhea
  • ≥2 years old, with unilateral or bilateral acute otitis media (AOM), with non-severe illness (mild otalgia for <48 hours & fever <39°C)
  • Recurrent otitis media
Patient Who May be Observed Initially (Ensure follow-up)
  • 6-23 months old, with unilateral uncomplicated acute otitis media (AOM) & presenting with non-severe illness (mild otalgia for <48 hours & fever <39°C)
  • ≥2 years old, with unilateral or bilateral uncomplicated acute otitis media (AOM), with confirmed diagnosis, & presenting with non-severe illness (no otorrhea)
Patients Who have been Previously Treated with Antibiotics
  • Children previously treated with Amoxicillin within the last 30 days or diagnosed with concurrent purulent conjunctivitis or with a history of recurrent unresponsive to Amoxicillin, should be given antibiotics with beta-lactamase coverage
  • Shift to other antibiotics if child’s symptoms worsen or disease is unresponsive within 48-72 hours of treatment


Symptomatic Therapy


  • Eg Paracetamol (Acetaminophen), Ibuprofen
  • Considered the mainstay of pain relief for acute otitis media (AOM)
  • Effective analgesia for mild-moderate pain

Topical agents

  • Eg Benzocaine, Lidocaine, Procaine
  • May provide temporary relief in patients >5 years old
Antibiotic Therapy
Amoxicillin/High-dose Amoxicillin
  • Amoxicillin at sufficient doses is still considered the 1st-line agent for AOM
  • Recommended for pediatric patients without history of antibiotic intake within the last 30 days prior to administration of Amoxicillin
    • Child should be concurrent purulent conjunctivitis-free & without history of allergy to Penicillin
  • It is effective against most of the bacteria which cause AOM including susceptible & intermediate-resistant pneumococci
  • In areas where penicillin-resistant/nonsusceptible pneumococci are common, high-dose Amoxicillin should be given
Amoxicillin/Clavulanic acid (High dose)
  • High doses of Amoxicillin combined with Clavulanic acid are recommended for patients who fail standard Amoxicillin therapy or in those who present with severe or recurrent illness
  • This combination will provide coverage for beta-lactamase producing organisms (eg H influenzae & M catarrhalis) along with Penicillin-resistant/nonsusceptible S pneumoniae
  • Effective against beta-lactamase producing bacterial strains (eg S pneumoniae, H influenzae & M catarrhalis)
  • Indicated for treatment of infections resistant to single therapy with beta-lactam or cephalosporins
Ceftriaxone [Intravenous (IV)/Intramuscular (IM)]
  • May be considered in patients unable to take oral medications
  • Treatment x 3 days is also recommended in patients who have failed Amoxicillin/clavulanic acid therapy & those with type I allergy to Penicillin
  • Has superior efficacy to S pneumoniae compared with alternative oral antibiotics
Cephalosporins (2nd & 3rd Generation)
  • Cefdinir, Cefixime, Cefpodoxime, Cefprozil & Cefuroxime are the preferred agents because of their effectiveness against drug resistant S pneumoniae, H influenzae & M catarrhalis
  • Cefdinir, Cefpodoxime & Cefuroxime are highly unlikely to develop cross-reactivity to Penicillin
  • These agents may be considered in patients with non-type 1 hypersensitivity reaction to Penicillin
  • May be given to patients w/ type I allergy to Penicillin & those refractory to advanced antibiotic therapy
  • May be considered in a patient who has persistent AOM after previous complete antibiotic therapy & in whom tympanocentesis is not possible for Gram stain & culture
  • Clindamycin may be effective against Penicillin-resistant pneumococcal infection not responding to other treatment
  • Clindamycin is not active against H influenzae or M catarrhalis & should not be used if these organisms are suspected
  • Co-trimoxazole may be considered in patients with type 1 allergy to Penicillin
  • Eg Azithromycin, Clarithromycin, Erythromycin
  • May be given to patients w/ type 1 allergy to Penicillin & those refractory to advanced antibiotic therapy
  • Less efficacy against S pneumoniae & H influenzae compared to Penicillin
    • Drug resistance to pneumococcus should be checked
  • Depending on local resistance patterns, may be preferred over Co-trimoxazole
Duration of Antibiotic Therapy
  • Optimal duration of antimicrobial therapy in AOM patients is uncertain; should depend on patient's age and disease severity
Patient <2 years old, severe illness or complicated presentation
  • Continue antibiotics x 10 days
Patient 2-5 years old, mild-moderate illness & uncomplicated presentation
  • Continue antibiotics x 7 days
Patient ≥6 years old, mild-moderate illness & uncomplicated presentation
  • Continue antibiotics x 5-7 days

Non-Pharmacological Therapy

Pain Management
  • Application of warm or cold compress on the affected ear may help alleviate pain
  • Oil drops applied on the external auditory canal may also be helpful
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