Diagnosis of acute otitis media

Acute otitis media is a common paediatric presentation in primary care; it rarely occurs in adults. It is characterised by middle ear inflammation and middle ear effusion.

Acute otitis media can be diagnosed if there is acute onset of either of the following signs on examination:

  • signs of inflammation (eg pain, bulging of the tympanic membrane) plus middle ear effusion
  • otorrhoea (indicative of tympanic membrane perforation and middle ear effusion, provided acute diffuse otitis externa has been excluded)Lieberthal, 2013.

Although visualising the tympanic membrane is considered important to confirm the diagnosis of acute otitis media, this may be difficult in the presence of copious otorrhoea, particularly in children. If the tympanic membrane cannot be visualised initially, ensure the patient is reviewed to check progress and reassess the membrane; review by an otolaryngologist or audiologist can aid diagnosis.

Middle ear effusion can occur in both acute otitis media, in which the effusion is infected, and otitis media with effusion, in which the effusion is not infected. Middle ear effusion can be diagnosed by demonstration of an immobile tympanic membrane on pneumatic otoscopy or a type B tympanogram; nonpneumatic otoscopy is not usually sufficient to detect effusionGunasekera, 2009Lieberthal, 2013. Consider a diagnosis of otitis media with effusion if middle ear effusion is not accompanied by other signs or symptoms of acute otitis media, such as fever, irritability, poor feeding, bulging tympanic membrane or acute onset of ear pain (in young children, ear pain may be indicated by tugging, holding or rubbing the ear)Gaddey, 2019Lieberthal, 2013. Pain or redness alone are not sufficient for diagnosis of acute otitis mediaLegros, 2008Weiss, 1996.

Note: Pain or redness alone are not sufficient for diagnosis of acute otitis media.

In children 2 months or younger, the clinical signs of serious infection are usually nonspecific. Even if the diagnosis of acute otitis media is clear, consider early assessment for and, if indicated, intervention for sepsis or septic shock – see Principles of managing sepsis and septic shock for advice on early recognition of and intervention for sepsis and septic shockNozicka, 1999Turner, 2002Ziv, 2019.