Episodic SOAP

October 1, 2013 ◆ Volume 88, Number 7 www.aafp.org/afp American Family Physician 435

Otitis Media: Diagnosis and Treatment
KATHRYN M. HARMES, MD; R. ALEXANDER BLACKWOOD, MD, PhD; HEATHER L. BURROWS, MD, PhD;
JAMES M. COOKE, MD; R. VAN HARRISON, PhD; and PETER P. PASSAMANI, MD
University of Michigan Medical School, Ann Arbor, Michigan

O
titis media is among the most
common issues faced by phy-
sicians caring for children.
Approximately 80% of children

will have at least one episode of acute otitis
media (AOM), and between 80% and 90%
will have at least one episode of otitis media
with effusion (OME) before school age.1,2
This review of diagnosis and treatment of
otitis media is based, in part, on the Uni-
versity of Michigan Health System’s clinical
care guideline for otitis media.2

Etiology and Risk Factors
Usually, AOM is a complication of eusta-
chian tube dysfunction that occurred during
an acute viral upper respiratory tract infec-
tion. Bacteria can be isolated from middle
ear fluid cultures in 50% to 90% of cases of
AOM and OME. Streptococcus pneumoniae,
Haemophilus influenzae (nontypable), and
Moraxella catarrhalis are the most common
organisms.3,4 H. influenzae has become the
most prevalent organism among children
with severe or refractory AOM following
the introduction of the pneumococcal con-
jugate vaccine.5-7 Risk factors for AOM are
listed in Table 1.8,9

Diagnosis
Previous diagnostic criteria for AOM were
based on symptomatology without oto-
scopic findings of inflammation. The
updated American Academy of Pediatrics
guideline endorses more stringent otoscopic
criteria for diagnosis.8 An AOM diagnosis
requires moderate to severe bulging of the
tympanic membrane (Figure 1), new onset

Acute otitis media is diagnosed in patients with acute onset, presence of middle ear effusion,
physical evidence of middle ear inflammation, and symptoms such as pain, irritability, or fever.
Acute otitis media is usually a complication of eustachian tube dysfunction that occurs dur-
ing a viral upper respiratory tract infection. Streptococcus pneumoniae, Haemophilus influen-
zae, and Moraxella catarrhalis are the most common organisms isolated from middle ear fluid.
Management of acute otitis media should begin with adequate analgesia. Antibiotic therapy
can be deferred in children two years or older with mild symptoms. High-dose amoxicillin (80
to 90 mg per kg per day) is the antibiotic of choice for treating acute otitis media in patients who
are not allergic to penicillin. Children with persistent symptoms despite 48 to 72 hours of anti-
biotic therapy should be reexamined, and a second-line agent, such as amoxicillin/clavulanate,
should be used if appropriate. Otitis media with effusion is defined as middle ear effusion in
the absence of acute symptoms. Antibiotics, decongestants, or nasal steroids do not hasten the
clearance of middle ear fluid and are not recommended. Children with evidence of anatomic
damage, hearing loss, or language delay should be referred to an otolaryngologist. (Am Fam
Physician. 2013;88(7):435-440. Copyright © 2013 American Academy of Family Physicians.)

▲

See related editorials
at http://www.aafp.org/
afp/2013/1001/od1.html
and http://www.aafp.
org/afp/2013/1001/od2.
html.

▲

Patient information:
A handout on this topic
is available at http://
familydoctor.org/family
doctor/en/diseases-
conditions/ear-infections/
treatment.html.

CME This clinical content
conforms to AAFP criteria
for continuing medical
education (CME). See CME
Quiz on page 429.

Author disclosure: No rel-
evant financial affiliations.

Table 1. Risk Factors for Acute Otitis
Media

Age (younger)

Allergies

Craniofacial abnormalities

Exposure to environmental smoke or other
respiratory irritants

Exposure to group day care

Family history of recurrent acute otitis media

Gastroesophageal reflux

Immunodeficiency

No breastfeeding

Pacifier use

Upper respiratory tract infections

Information from references 8 and 9.

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Otitis Media

436 American Family Physician www.aafp.org/afp Volume 88, Number 7 ◆ October 1, 2013

of otorrhea not caused by otitis externa, or mild bulg-
ing of the tympanic membrane associated with recent
onset of ear pain (less than 48 hours) or erythema. AOM
should not be diagnosed in children who do not have
objective evidence of middle ear effusion.8 An inaccu-
rate diagnosis can lead to unnecessary treatment with
antibiotics and contribute to the development of antibi-
otic resistance.

OME is defined as middle ear effusion in
the absence of acute symptoms.10,11 If OME
is suspected and the presence of effusion on
otoscopy is not evident by loss of landmarks,
pneumatic otoscopy, tympanometry, or both
should be used.11 Pneumatic otoscopy is a use-
ful technique for the diagnosis of AOM and
OME8-12 and is 70% to 90% sensitive and spe-
cific for determining the presence of middle
ear effusion. By comparison, simple otoscopy
is 60% to 70% accurate.10,11 Inflammation with
bulging of the tympanic membrane on otos-
copy is highly predictive of AOM.7,8,12 Pneu-
matic otoscopy is most helpful when cerumen
is removed from the external auditory canal.

Tympanometry and acoustic reflectom-
etry are valuable adjuncts to otoscopy or
pneumatic otoscopy.8,10,11 Tympanometry
has a sensitivity and specificity of 70% to
90% for the detection of middle ear fluid,
but is dependent on patient cooperation.13
Combined with normal otoscopy findings, a
normal tympanometry result may be help-
ful to predict absence of middle ear effusion.
Acoustic reflectometry has lower sensitivity
and specificity in detecting middle ear effu-
sion and must be correlated with the clinical
examination.14 Tympanocentesis is the pre-
ferred method for detecting the presence of
middle ear effusion and documenting bacte-
rial etiology,8 but is rarely performed in the
primary care setting.

Management of Acute Otitis Media
Treatment of AOM is summarized in Table 2.8

ANALGESICS

Analgesics are recommended for symptoms
of ear pain, fever, and irritability.8,15 Anal-
gesics are particularly important at bedtime
because disrupted sleep is one of the most
common symptoms motivating parents to
seek care.2 Ibuprofen and acetaminophen

have been shown to be effective.16 Ibuprofen is preferred,
given its longer duration of action and its lower toxic-
ity in the event of overdose.2 Topical analgesics, such as
benzocaine, can also be helpful.17

OBSERVATION VS. ANTIBIOTIC THERAPY

Antibiotic-resistant bacteria remain a major public health
challenge. A widely endorsed strategy for improving

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation
Evidence
rating References

An AOM diagnosis requires moderate to severe
bulging of the tympanic membrane, new
onset of otorrhea not caused by otitis externa,
or mild bulging of the tympanic membrane
associated with recent onset of ear pain (less
than 48 hours) or erythema.

C 8

Middle ear effusion can be detected with
the combined use of otoscopy, pneumatic
otoscopy, and tympanometry.

C 9

Adequate analgesia is recommended for all
children with AOM.

C 8, 15

Deferring antibiotic therapy for lower-risk
children with AOM should be considered.

C 19, 20, 23

High-dose amoxicillin (80 to 90 mg per kg per
day in two divided doses) is the first choice for
initial antibiotic therapy in children with AOM.

C 8, 10

Children with middle ear effusion and anatomic
damage or evidence of hearing loss or language
delay should be referred to an otolaryngologist.

C 11

AOM = acute otitis media.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-
quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual
practice, expert opinion, or case series. For information about the SORT evidence
rating system, go to http://www.aafp.org/afpsort.

Figure 1. Otoscopic view of acute otitis media. Erythema and bulging
of the tympanic membrane with loss of normal landmarks are noted.

Otitis Media

October 1, 2013 ◆ Volume 88, Number 7 www.aafp.org/afp American Family Physician 437

the management of AOM involves deferring antibiotic
therapy in patients least likely to benefit from antibiot-
ics.18 Antibiotics should be routinely prescribed for chil-
dren with AOM who are six months or older with severe
signs or symptoms (i.e., moderate or severe otalgia, otal-
gia for at least 48 hours, or temperature of 102.2°F [39°C]
or higher), and for children younger than two years with

bilateral AOM regardless of additional signs
or symptoms.8

Among children with mild symptoms,
observation may be an option in those six to
23 months of age with unilateral AOM, or in
those two years or older with bilateral or uni-
lateral AOM.8,10,19 A large prospective study
of this strategy found that two out of three
children will recover without antibiotics.20
Recently, the American Academy of Family
Physicians recommended not prescribing
antibiotics for otitis media in children two
to 12 years of age with nonsevere symptoms
if observation is a reasonable option.21,22 If
observation is chosen, a mechanism must
be in place to ensure appropriate treatment
if symptoms persist for more than 48 to 72

hours. Strategies include a scheduled follow-up visit or
providing patients with a backup antibiotic prescription
to be filled only if symptoms persist.8,20,23

ANTIBIOTIC SELECTION

Table 3 summarizes the antibiotic options for children
with AOM.8 High-dose amoxicillin should be the initial

Table 2. Treatment Strategy for Acute Otitis Media

Initial presentation

Diagnosis established by physical examination findings and presence of symptoms

Treat pain

Children six months or older with otorrhea or severe signs or symptoms
(moderate or severe otalgia, otalgia for at least 48 hours, or temperature
of 102.2°F [39°C] or higher): antibiotic therapy for 10 days

Children six to 23 months of age with bilateral acute otitis media without
severe signs or symptoms: antibiotic therapy for 10 days

Children six to 23 months of age with unilateral acute otitis media without
severe signs or symptoms: observation or antibiotic therapy for 10 days

Children two years or older without severe signs or symptoms: observation
or antibiotic therapy for five to seven days

Persistent symptoms (48 to 72 hours)

Repeat ear examination for signs of otitis media

If otitis media is present, initiate or change antibiotic therapy

If symptoms persist despite appropriate antibiotic therapy, consider
intramuscular ceftriaxone (Rocephin), clindamycin, or tympanocentesis

Information from reference 8.

Table 3. Recommended Antibiotics for (Initial or Delayed) Treatment and for Patients Who Have
Failed Initial Antibiotic Therapy

The rights holder did not grant the American Academy of Family Physicians the right to sublicense this material to a third party. For the
missing item, see the original print version of this publication.

Reprinted with permission from Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics.
2013;131(3):e983.

Otitis Media

438 American Family Physician www.aafp.org/afp Volume 88, Number 7 ◆ October 1, 2013

treatment in the absence of a known allergy.8,10,24 The
advantages of amoxicillin include low cost, acceptable
taste, safety, effectiveness, and a narrow microbiologic
spectrum. Children who have taken amoxicillin in the
past 30 days, who have conjunctivitis, or who need cover-
age for β-lactamase–positive organisms should be treated
with high-dose amoxicillin/clavulanate (Augmentin).8

Oral cephalosporins, such as cefuroxime (Ceftin),
may be used in children who are allergic to penicillin.
Recent research indicates that the degree of cross reac-
tivity between penicillin and second- and third-genera-
tion cephalosporins is low (less than 10% to 15%), and
avoidance is no longer recommended.25 Because of their
broad-spectrum coverage, third-generation cephalospo-
rins in particular may have an increased risk of selec-
tion of resistant bacteria in the community.26 High-dose
azithromycin (Zithromax; 30 mg per kg, single dose)
appears to be more effective than the commonly used
five-day course, and has a similar cure rate as high-dose
amoxicillin/clavulanate.8,27,28 However, excessive use of
azithromycin is associated with increased resistance, and
routine use is not recommended.8 Trimethoprim/sulfa-
methoxazole is no longer effective for the treatment of
AOM due to evidence of S. pneumoniae resistance.29

Intramuscular or intravenous ceftriaxone (Rocephin)
should be reserved for episodes of treatment failure or
when a serious comorbid bacterial infection is sus-
pected.2 One dose of ceftriaxone may be used in children
who cannot tolerate oral antibiotics because it has been
shown to have similar effectiveness as high-dose amoxi-
cillin.30,31 A three-day course of ceftriaxone is superior to
a one-day course in the treatment of nonresponsive AOM
caused by penicillin-resistant S. pneumoniae.31 Although
some children will likely benefit from intramuscular cef-
triaxone, overuse of this agent may significantly increase
high-level penicillin resistance in the community.2 High-
level penicillin-resistant pneumococci are also resistant
to first- and third-generation cephalosporins.

Antibiotic therapy for AOM is often associated with
diarrhea.8,10,32 Probiotics and yogurts containing active
cultures reduce the incidence of diarrhea and should be
suggested for children receiving antibiotics for AOM.32

There is no compelling evidence to support the use of
complementary and alternative treatments in AOM.8

PERSISTENT OR RECURRENT AOM

Children with persistent, significant AOM symptoms
despite at least 48 to 72 hours of antibiotic therapy
should be reexamined.8 If a bulging, inflamed tympanic
membrane is observed, therapy should be changed to a
second-line agent.2 For children initially on amoxicillin,
high-dose amoxicillin/clavulanate is recommended.8,10,28
For children with an amoxicillin allergy who do not
improve with an oral cephalosporin, intramuscular
ceftriaxone, clindamycin, or tympanocentesis may be
considered.4,8 If symptoms recur more than one month
after the initial diagnosis of AOM, a new and unrelated
episode of AOM should be assumed.10

For children with recurrent AOM (i.e., three or more
episodes in six months, or four episodes within 12
months with at least one episode during the preceding
six months) with middle ear effusion, tympanostomy
tubes may be considered to reduce the need for systemic
antibiotics in favor of observation, or topical antibiot-
ics for tube otorrhea.8,10 However, tympanostomy tubes
may increase the risk of long-term tympanic membrane
abnormalities and reduced hearing compared with med-
ical therapy.33 Other strategies may help prevent recur-
rence (Table 4).34-37

Probiotics, particularly in infants, have been suggested
to reduce the incidence of infections during the first year
of life. Although available evidence has not demonstrated
that probiotics prevent respiratory infections,38 probiot-
ics do not cause adverse effects and need not be discour-
aged. Antibiotic prophylaxis is not recommended.8

Management of OME
Management of OME is summarized in Table 5.11 Two
rare complications of OME are transient hearing loss
potentially associated with language delay, and chronic
anatomic injury to the tympanic membrane requiring
reconstructive surgery.11 Children should be screened
for speech delay at all visits. If a developmental delay
is apparent or middle ear structures appear abnormal,
the child should be referred to an otolaryngologist.11
Antibiotics, decongestants, and nasal steroids do not
hasten the clearance of middle ear fluid and are not
recommended.11,39

Tympanostomy Tube Placement
Tympanostomy tubes are appropriate for children six
months to 12 years of age who have had bilateral OME
for three months or longer with documented hearing

Table 4. Strategies for Preventing Recurrent
Otitis Media

Check for undiagnosed allergies leading to chronic rhinorrhea

Eliminate bottle propping and pacifiers34

Eliminate exposure to passive smoke35

Routinely immunize with the pneumococcal conjugate and
influenza vaccines36

Use xylitol gum in appropriate children (two pieces, five times a
day after meals and chewed for at least five minutes)37

Information from references 34 through 37.

Otitis Media

October 1, 2013 ◆ Volume 88, Number 7 www.aafp.org/afp American Family Physician 439

difficulties, or for children with recurrent AOM who have
evidence of middle ear effusion at the time of assessment
for tube candidacy. Tubes are not indicated in children
with a single episode of OME of less than three months’
duration, or in children with recurrent AOM who do not
have middle ear effusion in either ear at the time of assess-
ment for tube candidacy. Children with chronic OME
who did not receive tubes should be reevaluated every
three to six months until the effusion is no longer pres-
ent, hearing loss is detected, or structural abnormalities
of the tympanic membrane or middle ear are suspected.40

Children with tympanostomy tubes who present with
acute uncomplicated otorrhea should be treated with
topical antibiotics and not oral antibiotics. Routine,
prophylactic water precautions such as ear plugs, head-
bands, or avoidance of swimming are not necessary for
children with tympanostomy tubes.40

Special Populations
INFANTS EIGHT WEEKS OR YOUNGER

Young infants are at increased risk of severe sequelae
from suppurative AOM. Middle ear pathogens found in
neonates younger than two weeks include group B strep-
tococcus, gram-negative enteric bacteria, and Chlamydia
trachomatis.41 Febrile neonates younger than two weeks
with apparent AOM should have a full sepsis workup,
which is indicated for any febrile neonate.41 Empiric
amoxicillin is acceptable for infants older than two
weeks with upper respiratory tract infection and AOM
who are otherwise healthy.42

ADULTS

There is little published information to guide the man-
agement of otitis media in adults. Adults with new-onset
unilateral, recurrent AOM (greater than two episodes per
year) or persistent OME (greater than six weeks) should

receive additional evaluation to rule out a serious under-
lying condition, such as mechanical obstruction, which
in rare cases is caused by nasopharyngeal carcinoma.
Isolated AOM or transient OME may be caused by eusta-
chian tube dysfunction from a viral upper respiratory
tract infection; however, adults with recurrent AOM or
persistent OME should be referred to an otolaryngologist.

Data Sources: We reviewed the updated Agency for Healthcare
Research and Quality Evidence Report on the management of acute otitis
media, which included a systematic review of the literature through July
2010. We searched Medline for literature published since July 1, 2010,
using the keywords human, English language, guidelines, controlled
trials, and cohort studies. Searches were performed using the follow-
ing terms: otitis media with effusion or serous effusion, recurrent otitis
media, acute otitis media, otitis media infants 0-4 weeks, otitis media
adults, otitis media and screening for speech delay, probiotic bacteria
after antibiotics. Search dates: October 2011 and August 14, 2013.

EDITOR’S NOTE: This article is based, in part, on an institution-wide guide-
line developed at the University of Michigan. As part of the guideline
development process, authors of this article, including representatives
from primary and specialty care, convened to review current literature
and make recommendations for diagnosis and treatment of otitis media
and otitis media with effusion in primary care.

The Authors

KATHRYN M. HARMES, MD, is medical director of Dexter Health Center
in Ann Arbor, Mich. She is a clinical lecturer in the Department of Family
Medicine at the University of Michigan Medical School in Ann Arbor.

R. ALEXANDER BLACKWOOD, MD, PhD, is an associate professor in the
Department of Pediatrics at the University of Michigan Medical School.

HEATHER L. BURROWS, MD, PhD, is a clinical assistant professor in the
Department of Pediatrics and is associate director of education in the Divi-
sion of General Pediatrics at the University of Michigan Medical School.

JAMES M. COOKE, MD, is an assistant professor in the Department of
Family Medicine and is the director of the Family Medicine Residency Pro-
gram at the University of Michigan Medical School.

R. VAN HARRISON, PhD, is a professor in the Department of Medical Edu-
cation at the University of Michigan Medical School.

PETER P. PASSAMANI, MD, is an assistant professor in the Department of
Pediatric Otolaryngology at the University of Michigan Medical School.

Address correspondence to Kathryn M. Harmes, MD, University of
Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI
48109 (e-mail: [email protected]). Reprints are not available from
the authors.

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Table 5. Diagnosis and Treatment of Otitis
Media with Effusion

Evaluate tympanic membranes at every well-child and sick visit if
feasible; perform pneumatic otoscopy or tympanometry when
possible (consider removing cerumen)

If transient effusion is likely, reevaluate at three-month
intervals, including screening for language delay; if there
is no anatomic damage or evidence of developmental or
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an otolaryngologist

Antibiotics, decongestants, and nasal steroids are not indicated

Information from reference 11.

Otitis Media

440 American Family Physician www.aafp.org/afp Volume 88, Number 7 ◆ October 1, 2013

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