Acute middle ear infection with effusion and signs of inflammation, most common in young children.
Also known as: AOM, middle ear infection, ear infection, suppurative otitis media
Overview
Acute infection of the middle ear cleft characterized by middle ear effusion (MEE) plus rapid onset of signs and symptoms of middle ear inflammation. Distinguished from otitis media with effusion (OME), which lacks acute inflammatory signs.
Epidemiology
Most common bacterial infection of childhood; peak incidence 6-24 months. By age 3, ~80% of children have had at least one episode. Risk highest in fall/winter following viral URI.
Try two board-style Acute Otitis Media questions
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Question 1EENTEasy
A 3-year-old boy has ear pain and fever to 39.5°C. Examination shows bilaterally bulging, erythematous tympanic membranes. Which of the following is the most appropriate treatment?
ATympanostomy tube placement
BCiprofloxacin otic drops
CWatchful waiting for 48–72 hours
DHigh-dose oral amoxicillin
Reveal answer & full explanation
Correct answer: D — High-dose oral amoxicillin
ATympanostomy tube placement
BCiprofloxacin otic drops
CWatchful waiting for 48–72 hours
DHigh-dose oral amoxicillin✓
Why High-dose oral amoxicillin is correct
Bulging, erythematous tympanic membranes with otalgia and fever indicate acute otitis media; the fever of 39.5°C (≥39°C) and bilateral involvement make this severe disease
Per American Academy of Pediatrics guidance, severe acute otitis media warrants immediate antibiotics regardless of age, and high-dose amoxicillin (80-90 mg/kg/day) is first-line when the child has not recently taken amoxicillin and has no penicillin allergy
Amoxicillin-clavulanate or intramuscular ceftriaxone is used for treatment failure at 48-72 hours; cefdinir or azithromycin is an alternative in penicillin allergy
Why the others are wrong
Tympanostomy tube placement — reserved for recurrent acute otitis media or persistent effusion, not a first acute episode; the right-condition-wrong-step trap
Ciprofloxacin otic drops — appropriate for otitis externa or otorrhea through a perforation or tube, but topical drops do not treat infection behind an intact bulging membrane; buzzword-match on "ear drops"
Watchful waiting for 48–72 hours — an option only for non-severe acute otitis media without high fever, so the severe fever here excludes it; premature closure on the observation strategy
Question 2EENTEasy
A 3-year-old boy who attends daycare has had 4 episodes of acute otitis media this year, each with sudden ear pain, fever, and a bulging erythematous tympanic membrane. He has no penicillin allergy. Which of the following is the most appropriate first-line treatment for this episode?
AObservation
BTopical fluoroquinolone otic drops
CHigh-dose amoxicillin
DIntravenous ceftriaxone
Reveal answer & full explanation
Correct answer: C — High-dose amoxicillin
AObservation
BTopical fluoroquinolone otic drops
CHigh-dose amoxicillin✓
DIntravenous ceftriaxone
Why High-dose amoxicillin is correct
Acute otitis media (AOM) is the most common bacterial infection in children
Diagnostic criteria: bulging tympanic membrane (most important finding), acute onset, and middle ear effusion
Common pathogens: S. pneumoniae, H. influenzae (most common in recurrent AOM), and M. catarrhalis
First-line treatment: amoxicillin 80-90 mg/kg/day for 5-10 days
Why the others are wrong
Observation — appropriate only for mild cases in children ≥2 years without severe symptoms; this child has recurrent AOM and an active infection requiring treatment (confused-with watchful waiting)
Topical fluoroquinolone otic drops — used for otitis externa or AOM with tympanostomy tubes, not intact-membrane AOM (right-concept-wrong-route)
Intravenous ceftriaxone — reserved for treatment failure or when oral therapy is not tolerated; not first-line (premature escalation)
Additional high-yield points
Treatment failure (no improvement at 48-72 hours): switch to amoxicillin-clavulanate
Tympanostomy tube indications: recurrent AOM (3 episodes in 6 months or 4 episodes in 12 months); bilateral persistent otitis media with effusion with hearing loss above 40 dB for above 3 months
Tympanostomy tubes significantly reduce AOM frequency
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Absence of breastfeeding (breastfeeding ≥6 months is protective)
Craniofacial anomalies (cleft palate, Down syndrome)
Family history of recurrent AOM
Native American, Alaskan Native, and Australian Aboriginal ancestry
Pathophysiology
Viral URI causes eustachian tube dysfunction and mucosal edema, impairing middle ear drainage. Negative pressure draws nasopharyngeal secretions retrograde into the middle ear, where bacterial pathogens proliferate in the resulting effusion. Common bacterial pathogens: Streptococcus pneumoniae, non-typeable Haemophilus influenzae, Moraxella catarrhalis. Viruses (RSV, rhinovirus) may be the sole pathogen.
Clinical presentation
Symptoms
Ear pain (otalgia) — pulling/tugging at ear in preverbal children
In older children/adults: localized pain, sensation of ear fullness
Signs / physical exam
Bulging tympanic membrane — most specific sign
Loss of bony landmarks; opacification; yellow, white, or hemorrhagic color
Impaired TM mobility on pneumatic otoscopy
Air-fluid level or bubbles behind TM
Otorrhea through a perforation
Classic findings
Bulging, opacified TM with impaired mobility on pneumatic otoscopy in a febrile child with otalgia.
Differential diagnosis
Otitis media with effusion (OME) — Middle ear effusion without acute inflammatory signs; usually painless; hearing loss; no fever; observation appropriate
Otitis externa — Pain on tragal pressure or pinna traction, erythematous swollen canal with debris, normal TM if visible; treat with topical otic drops
Bullous myringitis — Painful bullae on TM; classically Mycoplasma but most often pneumococcus; treat as AOM
Mastoiditis — Postauricular erythema, swelling, fluctuance, protruding auricle, fever; CT temporal bone confirms; IV antibiotics ± surgical drainage
Foreign body in ear canal — Unilateral pain or discharge, often in toddlers; direct visualization; removal under microscopy
Dental pain referred — Posterior molar caries can refer pain to ear; normal otoscopy
TMJ dysfunction — Preauricular pain, clicking with jaw motion, normal TM
Diagnostic workup
Diagnostic criteria
AAP 2013: (1) Moderate-to-severe bulging of TM or new-onset otorrhea not due to otitis externa, OR (2) mild bulging with recent (<48 h) onset of ear pain or intense erythema of TM. Middle ear effusion must be present.
Labs
AOM is a clinical diagnosis; laboratory testing is rarely needed
Tympanocentesis with culture reserved for treatment failure, immunocompromised, or neonates
Imaging
Pneumatic otoscopy or tympanometry — confirms middle ear effusion when otoscopy ambiguous
CT temporal bone if mastoiditis, intracranial complication, or cholesteatoma suspected
Diagnostic algorithm
Age / Severity
Antibiotic Decision
Preferred Agent
<6 months, any severity
Antibiotics always
Amoxicillin or amox-clav
6-23 months, bilateral or severe
Antibiotics always
Amoxicillin 80-90 mg/kg/day
6-23 months, unilateral non-severe
Antibiotics OR 48-72 h observation
Amoxicillin if treating
≥24 months, severe (T≥39, severe pain, otorrhea)
Antibiotics always
Amoxicillin or amox-clav
≥24 months, non-severe
Antibiotics OR observation with follow-up
Amoxicillin if treating
Any age, treatment failure at 48-72 h
Switch antibiotic
Amoxicillin-clavulanate or ceftriaxone IM
AAP 2013 management algorithm for acute otitis media by age, severity, and treatment response.
Treatment
First-line
Amoxicillin 80-90 mg/kg/day divided BID × 10 days (5-7 days if age ≥6 y and non-severe) — preferred if no amoxicillin in prior 30 days, no concurrent purulent conjunctivitis, and no history of recurrent AOM unresponsive to amoxicillin
Amoxicillin-clavulanate 90 mg/kg/day amoxicillin component if any of the above risk factors are present, or for treatment failure at 48-72 h
Analgesia: acetaminophen or ibuprofen — addressed independently of antibiotic decision
Observation option (deferred antibiotics, reassess 48-72 h) for non-severe AOM in children ≥6 months without otorrhea — requires reliable follow-up
Second-line / adjunct
Cefdinir, cefuroxime, or cefpodoxime for non-anaphylactic penicillin allergy
Azithromycin or clindamycin for severe penicillin allergy (high resistance — use only when alternatives unavailable)
Ceftriaxone IM 50 mg/kg daily × 1-3 days for vomiting or oral intolerance
Tympanostomy tubes if ≥3 episodes in 6 months, ≥4 in 12 months, or persistent OME with hearing loss
Complications
TM perforation (usually heals spontaneously)
Mastoiditis — postauricular swelling, requires IV antibiotics ± mastoidectomy
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