Acute Otitis Media: Diagnosis and Treatment (AAP/AAFP Guidelines)

The American Academy of Pediatrics (AAP) and the American Academy of Family Practice (AAFP) published updated guidelines for the diagnosis and medical management of AOM.  

Otitis media (OM) is any inflammation of the middle ear. Otitis media is among the most common issues faced by physicians caring for children. Approximately 80% of children will have at least one episode of acute otitis media (AOM).

Acute otitis media is usually a complication of eustachian tube dysfunction that occurs during a viral upper respiratory tract infection. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms isolated from middle ear fluid.

Signs and symptoms

AOM implies rapid onset of disease associated with one or more of the following symptoms:

Otalgia, Otorrhea, Headache, Fever, Irritability, Loss of appetite, Vomiting, Diarrhea 


Pneumatic otoscopy is a useful technique for the diagnosis of AOM and is 70% to 90% sensitive and specific for determining the presence of middle ear effusion. By comparison, Simple otoscopy is 60% to 70% accurate.

Inflammation with bulging of the tympanic membrane on otoscopy is highly predictive of AOM. Pneumatic otoscopy is most helpful when cerumen is removed from the external auditory canal.

Tympanometry and Acoustic reflectometry are valuable adjuncts to otoscopy or pneumatic otoscopy. 


Figure 1. Otoscopic view of acute otitis media. Erythema and bulging of the tympanic membrane with loss of normal landmarks are noted.

 Treatment Strategy for Acute Otitis Media

Children six months or older with otorrhea or severe signs or symptoms (moderate or severe otalgia, otalgia for at least 48 hours, or temperature of 102.2°F [39°C] or higher): antibiotic therapy for 10 days.

Children six to 23 months of age with bilateral acute otitis media without severe signs or symptoms: antibiotic therapy for 10 days.

Children six to 23 months of age with unilateral acute otitis media without severe signs or symptoms: observation or antibiotic therapy for 10 days.

Children two years or older without severe signs or symptoms: observation or antibiotic therapy for five to seven days.

Persistent symptoms (48 to 72 hours).

Repeat ear examination for signs of otitis media.

If otitis media is present, initiate or change antibiotic therapy.

Antibiotic options for children with AOM. 

·        Management of acute otitis media should begin with adequate analgesia. Antibiotic therapy can be deferred in children two years or older with mild symptoms.

·        High-dose amoxicillin (80 to 90 mg per kg per day) is the antibiotic of choice for treating acute otitis media in patients who are not allergic to penicillin.

·        Children with persistent symptoms despite 48 to 72 hours of antibiotic therapy should be re-examined, and a second-line agent, such as amoxicillin/clavulanate, should be used if appropriate. 


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An AOM diagnosis requires moderate to severe bulging of the tympanic membrane, new onset of otorrhea not caused by otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear pain (less than 48 hours) or erythema.

Middle ear effusion can be detected with the combined use of otoscopy, pneumatic otoscopy, and tympanometry.

Adequate analgesia is recommended for all children with AOM.

Deferring antibiotic therapy for lower-risk children with AOM should be considered.

High-dose amoxicillin (80 to 90 mg per kg per day in two divided doses) is the first choice for initial antibiotic therapy in children with AOM.

Children with middle ear effusion and anatomic damage or evidence of hearing loss or language delay should be referred to an otolaryngologist.

AOM = acute otitis media.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. 

American Family Physician Journal
Medscape Reference
This is for informational purposes only. You should consult your clinical textbook for advising your patients.