Otitis Media: Types, Diagnosis, and Treatment
Types of Otitis Media
Otitis media encompasses three distinct clinical entities that require different management approaches:
Acute Otitis Media (AOM) is characterized by rapid onset of middle ear inflammation with fluid accumulation, presenting with acute symptoms such as ear pain, fever, and irritability 1. The diagnosis requires all three elements: acute symptom onset, presence of middle ear effusion documented by impaired tympanic membrane mobility, and signs of inflammation including moderate-to-severe bulging of the tympanic membrane or new otorrhea 2.
Otitis Media with Effusion (OME) presents as fluid in the middle ear without signs or symptoms of acute infection 1. This condition is diagnosed by reduced tympanic membrane mobility on pneumatic otoscopy, opaque tympanic membrane, or visible air-fluid interface, but critically lacks the acute inflammatory signs of AOM 1. OME persisting ≥3 months is classified as chronic OME 1.
Chronic Suppurative Otitis Media (CSOM) involves chronic middle ear and mastoid inflammation with a non-intact tympanic membrane (perforation or ventilation tube) and persistent ear discharge 1. No consensus exists on the exact duration of discharge required for diagnosis, with recommendations ranging from 2 weeks to at least 3 months 1.
Diagnostic Approach
For Acute Otitis Media, pneumatic otoscopy is the primary diagnostic tool and must demonstrate all three criteria: acute onset (symptoms <48 hours), middle ear effusion with impaired tympanic membrane mobility, and moderate-to-severe bulging or new otorrhea not caused by otitis externa 2. Tympanometry should be obtained if pneumatic otoscopy findings are equivocal 2. A common pitfall is diagnosing AOM based solely on tympanic membrane erythema without bulging or effusion—this does not constitute AOM and should not be treated with antibiotics 2, 3.
Severity classification is critical for treatment decisions. Severe AOM is defined by any of: moderate-to-severe otalgia, otalgia persisting ≥48 hours, or fever ≥39°C (102.2°F) 1, 2.
For Otitis Media with Effusion, diagnosis relies on demonstrating middle ear fluid without acute inflammatory signs 4. Pneumatic otoscopy showing reduced mobility, tympanometry demonstrating flat tracing, or visualization of air-fluid level confirms the diagnosis 1.
Treatment of Acute Otitis Media
Immediate Pain Management
Pain control must be addressed immediately in every patient, regardless of antibiotic decision 2. Acetaminophen or ibuprofen should be initiated within the first 24 hours and continued throughout the acute phase 2. This is critical because antibiotics provide no symptomatic relief in the first 24 hours, and 30% of children younger than 2 years still have pain or fever after 3-7 days of antibiotic therapy 2.
Antibiotic Decision Algorithm
For children <6 months: Immediate antibiotics are required for all cases 2.
For children 6-23 months:
- Severe AOM or bilateral non-severe AOM → immediate antibiotics 2
- Non-severe unilateral AOM with reliable follow-up → observation is appropriate 2
For children ≥24 months and adults:
- Severe symptoms → immediate antibiotics 2
- Non-severe symptoms with reliable follow-up → observation without immediate antibiotics is appropriate 2
Observation strategy requires: A mechanism ensuring follow-up within 48-72 hours, provision of a safety-net prescription to be filled only if symptoms worsen or fail to improve, and joint decision-making with parents 2.
First-Line Antibiotic Selection
High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses, maximum 2 grams per dose) is the first-line treatment for most patients 2. This dosing achieves middle ear fluid concentrations adequate to overcome resistance in Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, which account for approximately 70% of cases 2.
Switch to amoxicillin-clavulanate (90 mg/kg/day amoxicillin + 6.4 mg/kg/day clavulanate in 2 divided doses) when any of the following are present 2:
- Amoxicillin use within the prior 30 days
- Concurrent purulent conjunctivitis (suggesting H. influenzae)
- Attendance at daycare or high prevalence of beta-lactamase-producing organisms
Twice-daily dosing of amoxicillin-clavulanate results in significantly less diarrhea compared with three-times-daily dosing while providing equivalent efficacy 2.
Penicillin Allergy Alternatives
For non-severe (non-IgE-mediated) penicillin allergy, second- or third-generation cephalosporins are preferred, with cross-reactivity rates of only approximately 0.1%—far lower than historically reported 2:
- Cefdinir 14 mg/kg/day once daily (preferred for convenience) 2
- Cefuroxime 30 mg/kg/day divided twice daily 2
- Cefpodoxime 10 mg/kg/day divided twice daily 2
Treatment Duration
Children <2 years: 10-day course regardless of severity 2
Children 2-5 years:
Children ≥6 years:
Treatment Failure Management
Reassess at 48-72 hours if symptoms worsen or fail to improve 2. The escalation algorithm is:
- If initially observed → start high-dose amoxicillin 2
- If amoxicillin fails → switch to amoxicillin-clavulanate 2
- If amoxicillin-clavulanate fails → administer intramuscular ceftriaxone 50 mg/kg once daily for 3 consecutive days (a 3-day course is superior to a single-dose regimen) 2
Do not use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole for treatment failures, as pneumococcal resistance to these agents is substantial 2. Azithromycin should not be used first-line because macrolide resistance exceeds 40% in the United States, with bacterial failure rates of 20-25% 2.
For multiple treatment failures, consider tympanocentesis with culture and susceptibility testing 2. If unavailable, use clindamycin with adjunctive coverage for H. influenzae and M. catarrhalis 2. For multidrug-resistant S. pneumoniae serotype 19A, levofloxacin or linezolid may be used only after infectious disease and otolaryngology specialist consultation 2.
Critical Pitfall
Antibiotics do not prevent complications—33-81% of children who develop acute mastoiditis had received prior antibiotics 2. This underscores that antibiotic therapy, while beneficial for symptom resolution, does not eliminate complication risk.
Treatment of Otitis Media with Effusion
Watchful waiting for 3 months from diagnosis is the cornerstone of OME management, as 75-90% of residual OME after AOM resolves spontaneously within 3 months 4. Children should be followed every 3 months until effusion resolves 4.
Do not prescribe antibiotics for OME—they do not accelerate middle ear fluid clearance, and any initial benefit becomes non-significant within 2 weeks after stopping medication 4. Adverse effects include rashes, vomiting, diarrhea, allergic reactions, and development of bacterial resistance 4.
Do not use antihistamines, decongestants, or nasal steroids—these are ineffective for OME 4.
Obtain age-appropriate hearing testing if OME persists ≥3 months 2, 4.
Tympanostomy tube placement is indicated for 4:
- Bilateral persistent disease >3 months with documented hearing loss
- Significant impact on child's well-being
- Language delay or developmental concerns
Children with severe visual impairments should be considered more vulnerable to OME sequelae, as they rely more heavily on hearing 4.
Post-Treatment Expectations
Middle ear effusion persists in 60-70% of children at 2 weeks after successful AOM treatment, declining to 40% at 1 month and 10-25% at 3 months 2. This post-AOM effusion is classified as OME and requires monitoring but not antibiotics unless it persists >3 months with hearing loss, bilateral disease with documented hearing difficulty, or structural abnormalities develop 2.
Recurrent AOM Management
Recurrent AOM is defined as ≥3 episodes in 6 months or ≥4 episodes in 12 months with at least one episode in the preceding 6 months 2.
Prevention strategies include 2:
- Pneumococcal conjugate vaccine (PCV-13)
- Annual influenza vaccination
- Breastfeeding for at least 6 months
- Reducing or eliminating pacifier use after 6 months
- Avoiding supine bottle feeding
- Minimizing daycare attendance when possible
- Eliminating tobacco smoke exposure
Long-term prophylactic antibiotics are not recommended, as the modest benefit does not justify the risks of antibiotic resistance 2.
Tympanostomy tube placement should be considered for children meeting recurrent AOM criteria, with failure rates of 21% for tubes alone and 16% for tubes with adenoidectomy 2. The additive benefit of adenoidectomy is age-dependent and controversial 2.
Treatment of Chronic Suppurative Otitis Media
For acute tube otorrhea (tympanostomy tube in place), topical antibiotics such as ciprofloxacin-dexamethasone are the treatment of choice rather than oral antibiotics 2. Avoid ototoxic topical preparations when tympanic membrane integrity is uncertain 2.