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ENT

Acute otitis media

A usually self-limiting middle-ear infection in children, diagnosed by the clinical picture and otoscopy; analgesia and safety-netting come first, with antibiotics reserved for children more likely to benefit or at higher risk.

In a nutshell

Most childhood acute otitis media settles with analgesia and safety-netting. Diagnose with the clinical picture and otoscopy, reserve antibiotics for higher-benefit or high-risk groups, and recognise mastoiditis, sepsis and intracranial spread early.

Classic presentation

A child after a cold with acute ear pain, fever or irritability and a bulging inflamed tympanic membrane; discharge may follow perforation.

Key points

  • A red tympanic membrane alone is not diagnostic; bulging with loss of landmarks is the useful otoscopic discriminator.
  • Symptoms usually last about 3 days and can last up to a week; most children improve without antibiotics.
  • Analgesia and safety-netting are the default. Decongestants and antihistamines do not help.
  • Consider phenazone/lidocaine eardrops only when no immediate oral antibiotic is given and there is no perforation or otorrhoea.
  • Otorrhoea at any age and bilateral disease in a child under 2 are the groups more likely to benefit from an antibiotic, but no, back-up or immediate prescribing may still be considered.
  • Systemic illness, high complication risk, post-auricular swelling, facial weakness, meningism or neurological signs require urgent escalation.

First-line investigation

Otoscopy with assessment of the child’s general condition and the area behind the ear; routine blood tests, imaging and swabs are not needed in uncomplicated disease.

Management

Recognise complications and systemic illness

  • Urgently assess severe systemic illness, sepsis, meningism, neurological signs, facial weakness and post-auricular swelling with a displaced or protruding pinna. Refer to hospital for suspected mastoiditis, meningitis, intracranial abscess or sinus thrombosis.2,3,1
  • Assess fever in children under 5 using the NICE fever pathway; fever in a child under 3 months is a high-risk presentation requiring urgent assessment.2,4

Confirm the diagnosis and control pain

  • Use the clinical picture and otoscopy. Bulging with reduced landmarks or a new perforation supports acute otitis media; a red drum alone is not diagnostic. Consider otitis media with effusion, otitis externa, referred pain, foreign body and trauma when findings do not fit.1,2
  • Give regular age- or weight-appropriate paracetamol or ibuprofen. Explain the usual course, advise against decongestants and antihistamines, and give explicit worsening and non-improvement safety-netting.2

Use the antimicrobial-stewardship pathway

  • For most children, consider no antibiotic or a back-up prescription; use the back-up if symptoms do not start to improve within 3 days or worsen rapidly or significantly. For otorrhoea at any age or bilateral disease under 2, consider no, back-up or immediate antibiotic prescribing according to clinical severity and preference.2,1
  • When an immediate oral antibiotic is not given and there is no perforation or otorrhoea, consider phenazone/lidocaine eardrops: 4 drops two or three times daily for up to 7 days. Review if not improving within 7 days or worsening sooner.2,3

Prescribe and escalate antibiotics safely

  • Offer immediate antibiotics to systemically very unwell children, those with signs of a more serious illness or those at high risk of complications. Amoxicillin is first choice for 5 to 7 days using the NG91 age bands and BNFc; clarithromycin is an alternative for penicillin allergy or intolerance when appropriate.2,5,6
  • If symptoms worsen after at least 2 to 3 days of first-choice treatment, use the current co-amoxiclav second-choice pathway or seek microbiology advice when allergy, contraindication or unusual disease changes the choice.2,1

Protect hearing and avoid low-value treatment

  • Do not perform routine blood tests, imaging or ear swabs in uncomplicated disease. Reassess persistent otorrhoea, recurrent episodes, persistent effusion, hearing difficulty, speech delay or atypical findings and use the appropriate hearing or ENT pathway.1,2

Safety-net and reassess the trajectory

  • Tell families to seek help if symptoms worsen rapidly or significantly, the child becomes systemically very unwell, symptoms fail to start improving after 3 days, or complications develop. New post-auricular swelling, facial weakness, meningism or neurological symptoms require urgent hospital assessment.2,3,1

Exam traps

  • A red drum after crying or fever is not enough for acute otitis media; look for bulging and loss of landmarks.
  • New otorrhoea with sudden pain relief suggests tympanic-membrane perforation, but it does not automatically mean the infection has resolved.
  • Anaesthetic/analgesic eardrops are not for a perforated or discharging ear and are not a substitute for an indicated oral antibiotic.
  • Post-auricular swelling with a protruding pinna suggests mastoiditis and needs urgent hospital assessment.
  • The under-2 antibiotic subgroup is bilateral disease; otorrhoea is the any-age subgroup.

Illustrations

Acute otitis media on otoscopyOtoscopic view in acute otitis media showing an inflamed, bulging tympanic membrane with loss of normal landmarks and light reflex; bulging is the key sign distinguishing acute otitis media from uncomplicated effusion.B. Welleschik, Wikimedia Commons · CC-BY-SA-3.0
Eustachian tube anatomy in a child versus an adultDiagram comparing the shorter, more horizontal infant Eustachian tube with the longer, more angled adult tube to explain increased childhood susceptibility.PassFinals · original
Mastoiditis clinical signsIllustration of post-auricular swelling and a protruding, displaced ear as seen in mastoiditis complicating acute otitis media.PassFinals · original

Key sources

  1. NICE CKS, Otitis media acute
  2. NICE, Otitis media (acute): antimicrobial prescribing (NG91)Published 28 Mar 2018 | Updated 11 Mar 2022
  3. NICE NG91, update information including the 2025 sepsis-link update (NG91 update information)
  4. NICE, Fever in under 5s: assessment and initial management (NG143)Published 22 May 2019
  5. BNFc, Amoxicillin
  6. BNFc, Clarithromycin

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.