Treatment Guideline Chart
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

Otitis%20media%20-%20acute%20(pediatric) Management


  • Breastfeeding for at least 4-6 months, avoiding supine bottle feeding, exposure to persons with respiratory infections and tobacco smoke, and reducing pacifier use after 6 months of age may help prevent acute otitis media (AOM)
  • Pneumococcal conjugate vaccine may help in preventing vaccine-serotype pneumococcal otitis media
    • Introduction of PCV7 use significantly decreased carrier rate and incidence rate of AOM caused by S pneumoniae
    • Recommended as a 3-dose series given at 4-week intervals with booster dose given at 12-15 months of age for primary immunization
  • Annual influenza vaccine is recommended for all children ≥6 months of age for the prevention of AOM
    • Two doses separated by a 4-week interval should be administered to children 6 months to 8 years receiving influenza vaccine for the 1st time, then 1 dose yearly after initial dose
  • Further studies are needed to prove effectiveness of birch sugar (5-carbon polyol sugar alcohol) in prevention of acute and recurrent AOM

Expert Referral

Consider referral to pediatric infectious disease specialist if any of the following occurs:
  • If no response to 2nd-line agents
    • Tympanocentesis with Gram stain and culture is recommended
  • Otitis media with effusion (OME) for ≥3 months with bilateral hearing loss ≥20 dB
  • ≥3 episodes in 6 months; ≥4 episodes in 12 months
  • Retracted tympanic membrane (rule out significant pathology like cholesteatoma)
  • Complications of acute otitis media (AOM)
  • Speech or language delay
Consider referral for tympanostomy tube placement:
  • Patients with 3 episodes of AOM within 6 months, or 4 episodes within 1 year with 1 episode in the last 6 months, should be referred for tympanostomy tube placement

Follow Up

  • Clinicians should determine appropriate follow-up
Follow-up Strategies for Patients Initially Managed by Observation
  • Parent initiated follow-up visit or telephone call to clinic if worsening condition or no improvement at 48-72 hours
  • Routine follow-up call from clinic to patient 48-72 hours after initial visit
  • Scheduled follow-up appointment in 48-72 hours
  • Use of provisional antibiotic prescription with directions only if illness does not improve or worsens within 48-72 hours
Follow-up for Patients Treated with Antibiotics
  • Follow-up exam of asymptomatic patients at the completion of treatment is not necessary
  • It is recommended that follow-up exam is done 4-8 weeks after diagnosis
  • Middle ear effusion (MEE) can persist for up to 1-3 months even if there is bacteriologic cure
  • Persistence of MEE is not an indication for continued treatment or for another course of antibiotics
  • Hearing test should be performed if effusion is present 3 months post-acute otitis media (AOM)
    • Refer to otolaryngologist if hearing loss persists
Recurrent Acute Otitis Media
  • Defined as the presence of tympanic membrane bulging and inflammation of the middle ear after completion of therapy for AOM     
    • ≥3 separate episodes of AOM within 6 months or ≥4 episodes in a year with 1 episode in the past 6 months
  • Prophylactic antibiotic use is recommended for the prevention of recurrent AOM
    • Recommended antibiotics include Amoxicillin/clavulanic acid, Ceftriaxone, and Levofloxacin
  • Tympanostomy tube placement should be considered in children with ≥3 episodes of AOM within 6 months or ≥4 episodes in a year
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