Acute Otitis Media Guidelines

Updated: Dec 27, 2021
  • Author: John D Donaldson, MD, FRCSC, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Guidelines Summary

Guidelines for the diagnosis and management of AOM have been issued by the following organizations:

  • American Academy of Pediatrics (AAP)
  • University of Michigan Health System (UMHS)

The American Academy of Pediatrics (AAP) released revised clinical practice guidelines for the diagnosis and management of uncomplicated AOM in children aged 6 months through 12 years in 2013. [39, 40]  The updated recommendations, intended as a clinical decision-making framework for primary care physicians (PCPs), provide more rigorous diagnostic criteria intended to decrease unnecessary antibiotic use, as well as address therapeutic options, analgesia, prevention, and appropriate selection of antibiotics. They also discuss recurrent AOM, which was not covered in the previous guideline (2004). [39, 40]

The University of Michigan Health System published an update to its 2007 guidelines in 2013. A minor revision was released in 2014 to include information from the AAP that appeared after the publication of the guidelines. [41]


Diagnostic action statements from the AAP guidelines include the following [39, 40] :

  • AOM should be diagnosed when there is moderate to severe tympanic membrane bulging or new-onset otorrhea not caused by acute otitis externa

  • AOM may be diagnosed from mild tympanic membrane bulging and ear pain for less than 48 hours or from intense tympanic membrane erythema; in a nonverbal child, ear holding, tugging, or rubbing suggests ear pain

  • AOM should not be diagnosed when pneumatic otoscopy and/or tympanometry do not show middle ear effusion

The UMHS guidelines include the following recommendations [41] :

  • Symptoms of pain or fever, together with an inflammatory middle ear effusion, are required to make a diagnosis of AOM
  • The presence of middle ear effusion should be determined through the combined use of otoscopy, pneumatic otoscopy, and tympanometry when necessary


AAP management-related action statements include the following [39, 40] :

  • AOM management should include pain evaluation and treatment

  • Antibiotics should be prescribed for bilateral or unilateral AOM in children aged at least 6 months with severe signs or symptoms (moderate or severe otalgia or otalgia for 48 hours or longer or temperature 39°C or higher) and for nonsevere, bilateral AOM in children aged 6-23 months

  • On the basis of joint decision-making with the parents, unilateral, nonsevere AOM in children aged 6 -23 months or nonsevere AOM in older children may be managed either with antibiotics or with close follow-up and withholding of antibiotics unless the child worsens or does not improve within 48-72 hours of symptom onset

  • Amoxicillin is the antibiotic of choice unless the child received it within the previous 30 days, has concurrent purulent conjunctivitis, or is allergic to penicillin; in these cases, clinicians should prescribe an antibiotic with additional β-lactamase coverage

  • Clinicians should reevaluate a child whose symptoms have worsened or not responded to the initial antibiotic treatment within 48-72 hours and change treatment if indicated

  • In children with recurrent AOM, tympanostomy tubes, but not prophylactic antibiotics, may be indicated to reduce the frequency of AOM episodes

  • Clinicians should recommend pneumococcal conjugate vaccine and annual influenza vaccine to all children according to updated schedules

  • Clinicians should encourage exclusive breastfeeding for 6 months or longer

The UMHS guidelines concur overall with those of the AAP and include the following additional treatment recommendations [41] :

  • When antibiotic therapy is deferred, facilitate access to antibiotics if symptoms worsen (ie, a "back-up" prescription given at visit)
  • Amoxicillin is the first choice of antibiotic therapy; if amoxicillin is contraindicated, azithromycin is the appropriate first-line therapy
  • For AOM that is unresponsive to amoxicillin after 72 hours of therapy, administer amoxicillin-clavulanate or azithromycin 
  • Patients with significant, persistent symptoms on high-dose amoxicillin-clavulanate or azithromycin may respond to intramuscular ceftriaxone; the decision to use ceftriaxone should weigh the negative impact it will have on local antibiotic resistance

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) offers the following guidance on the use of tympanostomy tube insertion for children with AOM [42] :

  • Tympanostomy tube insertion should not be performed in children with recurrent AOM who do not have middle ear effusion (MEE) in either ear at the time of assessment for tube candidacy
  • Bilateral tympanostomy tube insertion should be performed in children who have unilateral or bilateral MEE at the time of assessment for tube candidacy
  • Educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications
  • Clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea
  • Encourage routine, prophylactic water precautions (use of earplugs or headbands; avoidance of swimming or water sports) for children with tympanostomy tubes

The French Society of Otorhinolaryngology (SFORL) issued clinical practice guidelines for the use of nonsteroidal antiinflammatory drugs (NSAIDs) in pediatric ENT infections in September 2019. [43]

In uncomplicated pediatric ENT infections, such as acute otitis media, tonsillitis, upper respiratory tract infections, and maxillary sinusitis, NSAIDs are indicated at analgesic doses (eg, ibuprofen 20-30 mg/kg/day) in combination with acetaminophen (in the following circumstances:

  • The pain intensity is determined to be medium (ie, a visual analogue scale [VAS] score of 3-5 or "Evaluation Enfant Douleur" [EVENDOL] child pain score of 4-7) and insufficiently responsive to first-line acetaminophen (residual VAS ≥3 or EVENDOL ≥4)
  • Pain is moderate to intense (VAS score 5-7 or EVENDOL score 7-10)

When combined, acetaminophen and ibuprofen should be taken simultaneously every 6 hours.

NSAIDS should not be prescribed to pediatric patients with severe or complicated ENT infections.

NSAIDs should be suspended in patients with infections that have unusual clinical presentations in terms of duration or symptoms.

NSAIDs should not be given for more than 72 hours.