Approach to managing acute otitis media

Acute otitis media is self-limiting. Spontaneous resolution occurs in more than 80% of children within 2 to 3 days; symptoms may persist for up to 7 days in some children.

Adequate pain relief is the mainstay of treatment for acute otitis media; for child dosages, see Oral drugs for mild, acute nociceptive pain in children, or for adult dosages, see Oral drugs for mild, acute nociceptive pain in adults. Decongestants, antihistamines and oral corticosteroids are not beneficial for acute otitis mediaGunasekera, 2009.

Note: Adequate pain relief is the mainstay of treatment for acute otitis media. Antibiotic therapy is not required for most patients.

Antibiotic therapy is commonly inappropriately prescribed and is of limited benefit in most patientsVenekamp, 2015:

Antibiotic therapy does not improve pain at 24 hours. For every 100 children treated with an antibiotic, only 5 children will be better at 2 to 3 days because of taking antibiotics; antibiotics only shorten the duration of symptoms by about 12 hours.
Antibiotic therapy does not significantly reduce the risk of complication by mastoiditis; almost 5 000 children would need antibiotic therapy to prevent one case of mastoiditisThompson, 2009.
Antibiotic therapy can cause harm (eg diarrhoea, rash or more serious hypersensitivity reactions, bacterial resistance) – see Types of adverse effects of antimicrobials.

A decision aid for consumers to support discussions is available from the Australian Commission on Safety and Quality in Health Care (ACSQHC).

Antibiotic therapy is more likely to prevent complications (eg perforation) in children:

with a cochlear implantHoberg, 2017 Kempf, 2000 Moon, 2022 Raveh, 2016 Rubin, 2010 Vila, 2017
with immune compromiseMarchisio, 1996
who reside in a remote community with a prevalence of chronic suppurative otitis media more than 4%Leach, 2020.

Antibiotic therapy may reduce the duration of symptoms (eg pain) by approximately 12 hours in children:

with otorrhoea
younger than 6 monthsRovers, 2006 Turner, 2002
younger than 2 years with bilateral infectionGunasekera, 2009 Lieberthal, 2013 Venekamp, 2015
who are systemically unwell (eg lethargic, pale, very irritable); fever alone is not an indication for antibiotic therapyLieberthal, 2013.

For children 2 years or younger, pain relief alone is appropriate; however, initial antibiotic therapy may be reasonable depending on the clinical context and likelihood of follow-up – clinical judgement is requiredGoldman, 2022.

Health outcomes are significantly impacted by geographical, historical, socioeconomic, spiritual, emotional and cultural determinants. Aboriginal and Torres Strait Islander children in some communities are more likely to be colonised from a young age with pathogens causing acute otitis media. In these children, acute otitis media often develops in the first months of life and recurs throughout childhood. Poor health outcomes of acute otitis media include loss of hearing, speech and learning delays, tympanic membrane perforation, chronic discharging ears and the consequent impact on education and social and emotional wellbeing. The incidence of infection and increased risk of poor health outcomes can be linked to complex socioeconomic factors, including poverty, reduced access to health services, discrimination and intergenerational trauma. A shared strengths-based approach to healthcare that recognises each child's unique cultural determinants and circumstances is essential. For treatment recommendations for Aboriginal and Torres Strait Islander children, see the Otitis Media Guidelines for Aboriginal and Torres Strait Islander Children.

Rare suppurative complications of acute otitis media include mastoiditis and facial palsy – urgent referral to the emergency department and otolaryngologist is required.