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.
Definition
Acute otitis media is acute inflammation and infection of the middle ear, usually in a child after a viral upper-respiratory infection. It is diagnosed clinically and most cases resolve without antibiotics.
Epidemiology
Commonest in young children, particularly during the first few years of life. Viral upper-respiratory infection, childcare exposure and passive smoke exposure increase risk. The NICE antimicrobial guideline covers children and young people under 18 years.
Pathophysiology
Viral mucosal swelling obstructs the Eustachian tube, impairing ventilation and drainage. Fluid accumulates behind the tympanic membrane and may become infected, producing pressure pain, bulging and conductive hearing symptoms. Perforation can release pressure and cause otorrhoea; spread into mastoid or intracranial structures causes rare but serious complications.
First principles
Eustachian-tube dysfunction traps infected fluid
A viral upper-respiratory infection can obstruct the Eustachian tube, impairing middle-ear ventilation and drainage. Fluid accumulates behind the tympanic membrane and may become infected by organisms from the nasopharynx. Young children are particularly susceptible because their Eustachian tubes are shorter and more horizontal.1,2
Bulging reflects pressure, while redness alone is non-specific
Inflammation and fluid pressure make the tympanic membrane painful and bulge outward, with reduced landmarks and light reflex. A red drum without bulging is not enough to diagnose acute otitis media because fever, crying and local irritation can also cause erythema.1
Most children improve without antibiotics
Acute otitis media is often viral, and viral and bacterial causes cannot reliably be separated clinically. Symptoms usually last about 3 days and may last up to a week; antibiotics make little difference to pain for most children and can cause diarrhoea or nausea. Prescribing is therefore risk-stratified rather than automatic.2,3
Post-auricular change means infection has spread beyond the middle ear
The middle ear communicates with mastoid air cells and lies close to facial-nerve and intracranial structures. Post-auricular swelling, tenderness and a displaced or protruding pinna, facial weakness, meningism or severe systemic illness are complication signs requiring urgent escalation.2,1
Presentation
Usually a child with a recent cold who develops acute ear pain, fever, irritability or ear-tugging, sometimes with reduced hearing. Otorrhoea can follow tympanic-membrane perforation and may relieve the pressure pain.2,1,4
Cardinal features
- Acute ear pain or ear-tugging and irritability in a pre-verbal child
- Fever or recent coryzal illness
- Bulging, inflamed tympanic membrane with reduced landmarks or light reflex
- Reduced hearing or a blocked-ear sensation
- Otorrhoea after tympanic-membrane perforation
Red flags
- Post-auricular swelling, erythema or tenderness with a protruding or displaced pinna
- Facial nerve weakness
- Meningism, severe headache, neurological signs or concern for intracranial spread
- Severe systemic illness, marked lethargy, shock or suspected sepsis
- Fever in a child under 3 months or rapid clinical deterioration
- Persistent or recurrent symptoms, persistent otorrhoea or suspected hearing or speech impact
Investigations
Otoscopy
Make the diagnosis clinically and inspect the tympanic membrane. Bulging or a new perforation with otorrhoea supports acute otitis media; a merely red drum is not diagnostic.
Expected finding: Inflamed, bulging tympanic membrane with loss of landmarks or light reflex, or discharge through a visible perforation.
1Assess systemic illness, age and complications
Record age, fever, hydration, general appearance, comorbidities, immune status and examination behind the ear and of the facial nerve. Fever in children under 5 must be assessed using the NICE fever pathway.
Expected finding: An otherwise well child with no post-auricular or neurological signs supports uncomplicated management; systemic or complication signs change the pathway.
2,4Consider alternative diagnoses and hearing impact
If otoscopy is not typical, consider otitis media with effusion, otitis externa, referred pain, foreign body or trauma. Persistent effusion, hearing loss, speech delay or recurrent disease needs reassessment and an appropriate hearing or ENT pathway rather than repeated empiric antibiotics.
Expected finding: A dull or retracted drum without acute inflammation suggests effusion; a normal drum suggests referred pain or another diagnosis.
1,2Microbiology only when clinically indicated
Routine blood tests, imaging and ear swabs are not needed for uncomplicated acute otitis media. Consider specialist advice or microbiology for persistent otorrhoea, treatment failure, unusual disease or a complication.
Expected finding: No routine investigation is required in a well child with uncomplicated, typical acute otitis media.
1,2Management
| Step | Detail | Source |
|---|---|---|
| Give analgesia and explain the expected course | Offer regular paracetamol or ibuprofen for pain, using the age- or weight-appropriate dose and maximum dose in the BNFc. Explain that symptoms usually last about 3 days and may last up to a week, and give clear advice to seek help if the child becomes systemically very unwell, worsens rapidly or significantly, or does not start to improve after 3 days. Decongestants and antihistamines do not improve symptoms.2 | NICE NG91, Otitis media (acute): antimicrobial prescribing |
| Consider anaesthetic and analgesic eardrops only when safe | If an immediate oral antibiotic is not being given and there is no tympanic-membrane perforation or otorrhoea, consider phenazone 40 mg/g with lidocaine 10 mg/g eardrops: 4 drops two or three times a day for up to 7 days. Review treatment if symptoms do not improve within 7 days or worsen at any time. Do not use these drops when the drum is perforated or the ear is discharging.2,3 | NICE NG91 recommendation 1.1.5 and treatment table |
| Use no antibiotic or a back-up prescription for most children | For children and young people not in a higher-benefit or high-risk group, consider no antibiotic or a back-up antibiotic prescription. Explain that antibiotics make little difference to pain at 24 hours and have adverse effects; a back-up prescription is used if symptoms do not start to improve within 3 days or worsen rapidly or significantly at any time.2 | NICE NG91 recommendations 1.1.8 to 1.1.10 |
| Use shared decision-making for otorrhoea or bilateral disease under 2 | For children of any age with otorrhoea, or children under 2 years with acute otitis media in both ears, consider no antibiotic, a back-up prescription or an immediate antibiotic. Weigh the modest increase in expected benefit against diarrhoea, nausea and antimicrobial-resistance harms, and give safety-netting whichever option is selected.2,1 | NICE NG91 recommendations 1.1.11 and 1.1.12 |
| Give immediate antibiotics to high-risk or systemically unwell children | Offer an immediate antibiotic prescription when the child is systemically very unwell, has symptoms or signs of a more serious illness, or is at high risk of complications because of relevant comorbidity or immunosuppression. First-choice oral antibiotic is amoxicillin for 5 to 7 days; use the NICE NG91 age bands and BNFc for the individual dose. For penicillin allergy or intolerance use clarithromycin when appropriate; if a macrolide is needed in pregnancy, erythromycin is preferred when antibiotic benefit outweighs harm.2,5,6 | NICE NG91 treatment table and BNFc |
| Escalate treatment failure appropriately | If symptoms worsen after at least 2 to 3 days of first-choice antibiotic treatment, use co-amoxiclav as the second-choice oral antibiotic according to the NICE NG91 table and BNFc, unless allergy, contraindication or microbiology advice changes the choice. Reassess the diagnosis and look for complications rather than repeatedly extending ineffective treatment.2,1 | NICE NG91 treatment table and NICE CKS |
| Refer urgently for mastoiditis, sepsis or intracranial complications | Refer to hospital when acute otitis media is associated with severe systemic infection or an acute complication such as mastoiditis, meningitis, intracranial abscess, sinus thrombosis or facial nerve paralysis. Post-auricular swelling with a protruding pinna is mastoiditis until assessed otherwise; do not manage this as routine uncomplicated otitis with oral antibiotics alone.2,3,1 | NICE NG91 recommendation 1.1.14 and current sepsis-link update |
| Review persistent, recurrent or complicated disease | Reassess children whose symptoms worsen, fail to improve, recur frequently, or remain associated with otorrhoea or hearing difficulty. Consider persistent effusion, recurrent acute otitis media, cholesteatoma, immune or anatomical disease and the child's hearing, speech and development; refer to paediatric or ENT services when the clinical course warrants it.1,2 | NICE CKS, Otitis media acute, and NICE NG91 |
Illustrations
Differentials
Otitis media with effusion
Dull, retracted or fluid-filled drum with hearing symptoms but no acute inflammatory illness or severe pain.
Otitis externa
Canal inflammation and pain on tragal or pinna movement, with the tympanic membrane normal if visible.
Referred otalgia
Normal otoscopy with a dental, throat, temporomandibular or other source.
Mastoiditis
Post-auricular swelling and tenderness with a protruding or displaced pinna; a complication rather than uncomplicated AOM.
Foreign body or trauma
Relevant history and direct canal or tympanic-membrane findings.
Complications
- Tympanic-membrane perforation and otorrhoea
- Mastoiditis
- Facial nerve palsy
- Meningitis, intracranial abscess or sinus thrombosis
- Persistent effusion and conductive hearing loss affecting communication or development
Prognosis
Most children improve within 3 days and symptoms can last up to a week. Antibiotics provide limited benefit for most uncomplicated cases, while otorrhoea and bilateral disease in children under 2 are more likely to benefit. Serious complications remain rare but need prompt recognition.
Guidelines
- Otitis media (acute): antimicrobial prescribing (NG91) (NICE, 2022)
- Fever in under 5s: assessment and initial management (NG143) (NICE, 2019)
References
- NICE CKS, Otitis media acute
- NICE, Otitis media (acute): antimicrobial prescribing (NG91)Published 28 Mar 2018 | Updated 11 Mar 2022
- NICE NG91, update information including the 2025 sepsis-link update (NG91 update information)
- NICE, Fever in under 5s: assessment and initial management (NG143)Published 22 May 2019
- BNFc, Amoxicillin
- BNFc, Clarithromycin
Evidence checked: 2026-08-03
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.