Acute Otitis Media (AOM)

NICE CKS Otitis media - acute. Last revised Aug 2024. NICE guideline [NG91] Otitis media (acute): antimicrobial prescribing. Last updated Mar 2022.

Background Information

AOM can be caused by both bacteria and viruses, commonly both are present at the same time.

Most common bacterial pathogen:
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Morexella catarrhalis
  • Streptococcus pyogenes


Viral pathogens associated with AOM:

  • Respiratory syncytial virus
  • Rhinovirus
  • Adenovirus
  • Influenza virus
  • Parainfluenza virus

  • Young
  • Male
  • Smoking and/or passive smoking
  • Increased exposure to viral illness (e.g. frequent contact with other children, having siblings)
  • Craniofacial abnormalities (e.g. cleft palate)
  • Gastro-oesophageal reflux
  • Immunodeficiency
  • Recurrent URTI

Guidelines

Clinical diagnosis.

Acute onset of symptoms:
  • Earache
  • Younger children: ear tugging / rubbing / holding


Otoscopic examination findings:

  • Red / yellow / cloudy tympanic membrane 
  • Bulging tympanic membrane
  • Tympanic membrane perforation and/or discharge in the external auditory canal
 
 

Clinical features that are NOT suggestive of AOM:

  • Non-bulging tympanic membrane
  • Air-fluid level without bulging tympanic membrane

These findings are more suggestive of middle ear effusion (glue ear).

Advise patients:
  • The usual course of AOM is usually ~3 days, but can be up to 1 week
  • No need to restrict from usual daily activities
  • Avoid swimming if there is  tympanic membrane perforation
  • Ear pain may worsen with air travel 
  • Children may return to school / day care once fever and otalgia resolved

Symptomatic management:
  • Paracetamol or ibuprofen
  • Consdier eardrops (phenazone + lidocaine) for pain
    • Only if antibiotics not given AND no tympanic membrane perforation

Indications for immediate antibiotic prescription:
  • Systemically unwell
  • Features of more serious illness / conditions 
  • At risk of complications

Consider antibiotics if:
  • Symptoms not improving within 3 days or worsen significantly or rapidly at any time
  • Bilateral AOM in <2 y/o
  • Presence of ear discharge (suggesting perforated tympanic membrane)
 

NICE noted that both viral and bacterial infections causing AOM are usually self-limiting and do not routinely require antibiotics.

1st line: amoxicillin for 5-7 days

If penicillin allergic / intolerance: clarithromycin for 5-7 days

If pregnant + penicillin allergic / intolerance: erythromycin for 5-7 days 
Author: Adams Lau
Reviewer:
Last Edited: 20/04/25