Otitis MediaMANAGEMENT

ENT AND MAXILLOFACIAL PRESENTATIONS · 12 SECTIONS

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635 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Acute laryngitis Acute pharyngitis Auricular hematoma Bezold's Abscess Cerumen impaction Dry socket Ear foreign body Epistaxis (anterior)Epistaxis (Posterior)Labyrinthitis Ludwig's Angina Malignant Otitis Externa Marcus Gunn Pupil Mastoiditis Meniere's Disease Nasal Bone Fracture Nasal foreign body Nasal Septal Hematoma Otitis externa Otitis Media Post-tonsillectomy hemorrhage Sialolithiasis and sialadenitis Sinusitis Sudden Sensorineural Hearing Loss TMJ dislocation Tympanic membrane perforation Vestibular Neuronitis

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp37

Danger signs and urgent escalation

›Complications of AOM requiring immediate action

›Postauricular swelling, erythema, or pinna protrusion

›Suspect acute mastoiditis

›CT temporal bone with IV contrast as first-line imaging

›ENT consultation immediately

›Headache, meningismus, or neck rigidity

›Intracranial complication (meningitis, epidural abscess, dural venous sinus thrombosis)

›MRI brain with IV contrast superior for intracranial extension

›Neurosurgery consultation if abscess or empyema detected

›Facial nerve palsy

›Temporal bone involvement

›ENT urgent consultation

›Vertigo or acute sensorineural hearing loss

›Labyrinthitis or inner ear involvement

›Audiological and ENT evaluation

›Toxic-appearing child with high fever

›IV access and fluid resuscitation

›Blood cultures before antibiotics

›Broad-spectrum IV antibiotics within 1 hour

Monitoring and targets

›Clinical monitoring bundle

›Vital signs including temperature and heart rate

›Temperature ≥39°C defines severe AOM

›Tachycardia in young infants warrants close monitoring

›Neurological status

›Level of consciousness

›Fontanelle status in infants

02History/hx72

Presenting symptoms

›Classic symptom complex

›Ear pain (otalgia)

›Ear tugging, rubbing, or holding in preverbal children

›Onset typically ~4 days after viral URI

›Fever

›Temperature ≥39°C defines severe AOM

›Fever duration and antipyretic response

›Irritability and sleep disturbance

›Particularly in infants

›Disrupted feeding patterns

›Otorrhea

›Indicates TM perforation

›New-onset discharge diagnostic of AOM when TM perforated

Symptom severity classification

›AAP severity stratification

›Nonsevere AOM

›Mild otalgia

›Temperature <39°C

›Severe AOM

›Moderate-to-severe otalgia

›Otalgia duration ≥48 hours

›Temperature ≥39°C

Risk factors

›Modifiable risk factors

›Daycare attendance

›Strongest modifiable risk factor (RR 2.45)

›Number of children in group matters

03Physical Exam/exam52

Otoscopic examination

›Tympanic membrane assessment

›TM bulging

›Moderate-to-severe bulging is defining feature of AOM

›Mild bulging with recent-onset ear pain (<48 hrs) also diagnostic

›TM erythema

›Intense erythema with bulging supports AOM

›Isolated erythema without bulging insufficient for diagnosis

›Crying alone can cause TM redness (pitfall)

›TM opacification

›Obscured landmarks (short process, malleus handle)

›Loss of light reflex

›TM perforation

›New-onset otorrhea diagnostic when otitis externa excluded

Pneumatic otoscopy

›Mobility assessment

›Decreased or absent TM mobility confirms middle-ear effusion

›Gold standard bedside tool

›Required to distinguish AOM from OME

›Normal mobility reduces likelihood of AOM

›Excludes significant effusion

Ear canal and periauricular exam

›External auditory canal

›Canal wall erythema or edema

›Otitis externa if canal involved

›Tragal tenderness or pinna traction pain distinguishes otitis externa

›Foreign body

›Cholesteatoma changes

04Differential Diagnosis/ddx50

Middle ear conditions

›Otitis media with effusion (OME)

›ICD-10: H65.9

›Middle-ear effusion without signs of acute infection

›No TM bulging; TM may be retracted or dull

›Does not require antibiotics

›Distinguished by absence of fever and otalgia

›Recurrent AOM

›ICD-10: H66.9

›≥3 episodes in 6 months or ≥4 in 12 months

›ENT referral for tympanostomy tube consideration

›Chronic suppurative otitis media

›ICD-10: H66.3

›Persistent TM perforation with otorrhea

›Foul-smelling discharge

External ear conditions

›Otitis externa

›ICD-10: H60.3

›Pain with tragal pressure or pinna traction

›Canal edema and debris; TM typically normal

›No middle-ear effusion on pneumatic otoscopy

›Malignant otitis externa

›Pseudomonas infection in diabetics or immunocompromised

›Granulation tissue at bony-cartilaginous junction

›Skull base osteomyelitis risk

Complications of AOM

›Acute mastoiditis

›ICD-10: H70.0

05Laboratory Tests/lt32

Routine laboratory assessment

›Routine labs for uncomplicated AOM

›Not indicated in uncomplicated, non-toxic cases

›Diagnosis is clinical

›Labs do not change management in uncomplicated AOM

›Complete blood count in suspected complications

›Leukocytosis suggests systemic infection

›Normal WBC does not exclude mastoiditis

›C-reactive protein

›Elevated in bacterial vs viral infection

›Cannot reliably distinguish AOM from OME

›Procalcitonin

›Useful marker when systemic bacterial infection suspected

›Better specificity than CRP for bacterial infection

Microbiological studies

›Blood cultures

›Indicated in toxic-appearing children

›Prior to antibiotic administration

›Bacteremia risk higher in infants <2 years

›Yield low in uncomplicated AOM

›Bacteremia estimated at <2% in well-appearing children with AOM

›Tympanocentesis culture

›Diagnostic and therapeutic in refractory cases

›Allows direct culture of middle-ear fluid

›Indicated after failure of multiple antibiotic courses

›Common pathogens recovered

›Streptococcus pneumoniae (most severe)

›Nontypable Haemophilus influenzae

06Diagnostic Tests/dt60

Scoring Systems

›AAP diagnostic criteria for AOM

›Moderate-to-severe TM bulging

›Sufficient for diagnosis alone

›Mild bulging with recent-onset otalgia <48 hours

›Or intense TM erythema

›New-onset otorrhea not due to otitis externa

›TM perforation with discharge diagnostic

›All three criteria absent excludes AOM diagnosis

›Severity classification (AAP)

›Nonsevere: mild otalgia, temperature <39°C

›Severe: moderate-to-severe otalgia, otalgia ≥48 hours, or temperature ≥39°C

›AAP watchful waiting eligibility criteria

›Age ≥6 months required to consider observation

›Unilateral AOM in children 6–23 months with mild symptoms

›Unilateral or bilateral AOM in children ≥2 years with mild symptoms

›Safety-net antibiotic prescription given with 48–72 hour follow-up

MRI

›MRI brain with IV contrast

›Superior modality for intracranial complications

›Epidural empyema detection

›Subdural empyema detection

›Brain abscess characterization

›Dural venous sinus thrombosis (MRV)

›Labyrinthitis

›Not first-line for uncomplicated mastoiditis

›Lower spatial resolution for bony detail than CT

›Complementary to CT in complicated mastoiditis

07Disposition/dispo44

Discharge criteria

›Safe for discharge

›Uncomplicated AOM in well-appearing child

›No toxic appearance

›No signs of complications

›Tolerating oral medications

›Reliable follow-up available

›Analgesics prescribed for all patients

›Acetaminophen or ibuprofen

›Clear return precautions documented

›Worsening pain or new drainage

›Fever not improving or temperature ≥39°C

›Postauricular swelling or redness

›Increasing irritability or lethargy

›Any neurological change

Admission indications

›Inpatient admission required

›Suspected mastoiditis or intracranial complication

›IV antibiotics and urgent specialist consultation

›Toxic-appearing child

›Sepsis workup and IV antimicrobials

›Infant <2 months with fever

›Full sepsis evaluation mandatory

›Failure of outpatient therapy with worsening symptoms

›Unable to tolerate oral medications

›Clinical deterioration despite antibiotics

›Surgical drainage may be required

›Subperiosteal abscess

08Treatment/t90

Analgesia

›Pain management for all patients with AOM

›Acetaminophen

›15 mg/kg per dose every 4–6 hours

›Maximum 5 doses per 24 hours

›First-line in infants <6 months

›Ibuprofen

›10 mg/kg per dose every 6–8 hours

›Age ≥6 months only

›Alternate with acetaminophen for severe pain

›Topical anesthetic ear drops

›Benzocaine or procaine otic drops for brief relief

›Avoid if TM perforation suspected

Watchful waiting (observation option)

›Observation without immediate antibiotics

›Children 6–23 months with mild unilateral AOM

›Mild otalgia and temperature <39°C

›Safety-net prescription given

›Children ≥2 years with mild symptoms

›Unilateral or bilateral mild AOM

›Reassess if no improvement in 48–72 hours

›Conditions where observation is NOT appropriate

›All children <6 months

›Bilateral AOM in children 6–23 months

›Severe AOM at any age

›Otorrhea present

›Immunocompromised patients

First-line antibiotic therapy

›Amoxicillin (first-line)

›Dose: 80–90 mg/kg/day divided every 12 hours

›High-dose strategy targets penicillin-resistant S. pneumoniae

›Superior pneumococcal coverage over standard dosing

›Duration

›10 days for children <2 years

›5–7 days for children ≥2 years with mild-to-moderate disease

›10-day course preferred in children <24 months (5-day course had approximately double failure rate)

›Class I recommendation per AAP guidelines

›Amoxicillin-clavulanate (when amoxicillin insufficient)

›Indications for amoxicillin-clavulanate

›Antibiotic use within prior 30 days

›Concurrent purulent conjunctivitis (conjunctivitis-otitis syndrome, suggests H. influenzae)

›Spontaneous TM perforation with otorrhea

›Failure of amoxicillin after 48–72 hours

›Dose: 90 mg/kg/day (amoxicillin component) divided every 12 hours

›Use 14:1 formulation (amoxicillin:clavulanate)

›Minimizes GI side effects from clavulanate

›Duration: 10 days

Penicillin allergy alternatives

›Non-anaphylactic penicillin allergy

›Cefdinir

›14 mg/kg/day once daily or divided every 12 hours

›10-day course

›Cefuroxime

›30 mg/kg/day divided every 12 hours

›10-day course

›Cefpodoxime

›10 mg/kg/day divided every 12 hours

›10-day course

›Anaphylactic penicillin allergy (avoid cephalosporins)

›Azithromycin

›Inferior pneumococcal coverage

›Reserved when cephalosporins contraindicated

›10 mg/kg day 1, then 5 mg/kg days 2–5

›Clindamycin for S. pneumoniae coverage if H. influenzae excluded

Refractory AOM management

›Treatment failure definition

›No clinical improvement after 48–72 hours of appropriate antibiotics

›Clinical worsening on appropriate antibiotics

›Step-up therapy

›If on amoxicillin: switch to amoxicillin-clavulanate

›If on amoxicillin-clavulanate: ceftriaxone IM

›Ceftriaxone 50 mg/kg/day IM or IV

›Duration: 3 days

›Effective against beta-lactamase-producing H. influenzae

›Tympanocentesis for culture in refractory cases

›Guides antibiotic selection

›Therapeutic drainage

Not recommended therapies

›Therapies without benefit in AOM

›Antihistamines and decongestants

›Not effective for AOM

›Associated with adverse effects including drowsiness and diarrhea

›May prolong middle-ear effusion

›Cochrane 2025 review confirms no benefit

›Systemic corticosteroids

›Lack evidence of benefit for AOM

›Cochrane 2018 review found no significant benefit

›Topical antibiotic drops (intact TM)

›Cannot penetrate intact TM

›No role in standard AOM

Tympanostomy tubes

›Surgical referral for tube placement

›Recurrent AOM criteria

›≥3 episodes in 6 months

›≥4 episodes in 12 months with ≥1 in past 6 months

›Bilateral OME with hearing loss >40 dB for ≥3 months

›Topical ofloxacin drops preferred for otorrhea in children with tubes

09Special Populations/sp60

Pregnancy

›AOM in pregnancy

›Physiologic considerations

›Eustachian tube dysfunction may worsen with rhinitis of pregnancy

›Mucosal edema from hormonal changes promotes middle-ear pressure changes

›Antibiotic safety in pregnancy

›Amoxicillin: Category B, safe in all trimesters

›Amoxicillin-clavulanate: Category B, generally safe

›Azithromycin: Category B, acceptable alternative

›Tetracyclines: Contraindicated (fetal bone and tooth development)

›Fluoroquinolones: Avoid in pregnancy

›Analgesics in pregnancy

›Acetaminophen: Safe in all trimesters, preferred analgesic

›Ibuprofen: Avoid after 20 weeks (premature ductus arteriosus closure risk)

›Imaging in pregnancy

›CT temporal bone: Limited use given radiation; use if mastoiditis suspected

›MRI preferred for intracranial complications (no ionizing radiation)

Geriatric

›AOM in older adults

›Epidemiology in elderly

›Less common than in children

›Often presents atypically without classic otalgia

›Hearing loss may mask new symptoms

›Clinical considerations

›Eustachian tube dysfunction from age-related mucosal changes

›Higher rates of comorbidities affecting antibiotic choice (CKD, liver disease)

›Drug interactions with common geriatric polypharmacy

›Antibiotic dosing adjustments

10Background/b68

Epidemiology

›Incidence and prevalence

›Most common diagnosis in childhood acute sick visits

›By age 3, 50–85% of children have had at least one AOM episode

›Annual cost estimated at >$5 billion USD in the United States

›Peak incidence 6–12 months of age

›Incidence declines sharply after age 2

›Rare in adults but can occur with eustachian tube dysfunction

›Mastoiditis complication rate approximately 2–4 per 10,000 AOM episodes

›Post-PCV13 era: S. pneumoniae prevalence reduced

›H. influenzae now proportionally more common

›Non-typable H. influenzae produces beta-lactamase in ~30–40%

›Global burden

›Leading cause of antibiotic prescribing in children worldwide

›Hearing loss from OME significant cause of speech and developmental delay

Pathophysiology

›Eustachian tube dysfunction

›Normal eustachian tube function

›Equalizes middle-ear pressure

›Drains middle-ear secretions to nasopharynx

›Protects from nasopharyngeal secretions

›Dysfunction mechanism

›Viral URI causes mucosal edema and eustachian tube obstruction

›Negative middle-ear pressure develops

›Nasopharyngeal bacteria ascend via dysfunctional tube

›Anatomic factors in children

›More horizontal and shorter eustachian tube than adults

›Floppy cartilage support

›Larger nasopharyngeal lymphoid tissue relative to tube orifice

›Inflammatory cascade

›Bacterial colonization triggers neutrophil recruitment

›Mucopurulent effusion accumulates in middle ear

›TM bulging from pressure

›Biofilm formation

›H. influenzae forms biofilm (antibiotic penetration challenge)

›Contributes to recurrent and refractory AOM

›Common pathogens

›Streptococcus pneumoniae

›Most virulent pathogen

›Higher treatment failure and complication rate

›Penicillin resistance mediated by altered penicillin-binding proteins

›Nontypable Haemophilus influenzae

›Most common pathogen post-PCV13

›Beta-lactamase production in ~30–40% of strains

›Associated with conjunctivitis-otitis syndrome

›Moraxella catarrhalis

›Beta-lactamase positive in >90% of strains

›More likely to resolve spontaneously than S. pneumoniae

Therapeutic Considerations

›Antibiotic stewardship rationale

›Spontaneous resolution rates

›OME: >90% resolve without antibiotics within 3 months

›Non-severe AOM: approximately 80% resolve without antibiotics

›Severe AOM: lower spontaneous resolution, antibiotics more clearly beneficial

›Number needed to treat (NNT)

›NNT approximately 7–8 to prevent one treatment failure

›NNT approximately 9 to prevent one contralateral AOM

›Antibiotic harms

›GI side effects (diarrhea, nausea) in 5–10%

›Rash in 5–7%

›Contributes to antibiotic resistance in community

›High-dose amoxicillin rationale

›Achieves middle-ear fluid concentrations exceeding MIC of penicillin-intermediate S. pneumoniae

›Standard dose (40–45 mg/kg/day) insufficient for resistant strains

›High-dose (80–90 mg/kg/day) achieves adequate drug exposure

›Safe and well-tolerated at high doses

›Vaccine impact on management

›PCV13 reduced invasive pneumococcal AOM by approximately 57%

›Shifted pathogen distribution toward H. influenzae

›Amoxicillin-clavulanate now more relevant in treatment failures

›Influenza vaccination reduces AOM episodes by approximately 30–36% during influenza season

11Patient Discharge Instructions/pdi30

copy discharge instructions

›Discharge instructions for Otitis Media (Ear Infection)

›Diagnosis explanation

›Your child has been diagnosed with acute otitis media (a middle ear infection)

›This infection is usually caused by bacteria that enter the ear after a cold or upper respiratory infection

›Most ear infections improve within 2–3 days even without antibiotics

›Medication instructions

›Give pain medicine (acetaminophen or ibuprofen) for ear pain or fever as directed

›If antibiotics were prescribed, complete the full course even if your child feels better

›Do not use antihistamines or decongestants — they do not help ear infections and can cause side effects

›If a prescription was given but not filled (watchful waiting), fill it and start it if your child does not improve in 48–72 hours

›Activity and care

›No restrictions on activity unless your child has fever or is in significant pain

›Keep water out of the ear if there is drainage or a known ear tube

›Continue breastfeeding if applicable — it protects against future ear infections

›Prevention guidance

›Pneumococcal and influenza vaccines reduce risk of ear infections

›Avoid tobacco smoke exposure in the home

›Avoid bottle propping (feeding infant lying flat with bottle)

›Limit pacifier use after 6 months of age when possible

›Smaller daycare settings reduce infection exposure

›Return to emergency department immediately if

›Swelling, redness, or tenderness behind the ear

›Ear pinna is pushed forward or outward

›Increasing irritability, lethargy, or poor feeding in infants

›High fever (≥39°C / 102.2°F) not improving

›Headache or stiff neck

›New ear drainage or worsening ear pain

12References/r40

Guidelines and key sources

›Primary clinical guidelines

›Shaikh N. Otitis Media in Young Children. New England Journal of Medicine. 2025

›Comprehensive 2025 NEJM review; primary evidence source for diagnostic algorithm, antibiotic selection, and watchful waiting criteria

›https://www.nejm.org/doi/full/10.1056/NEJMcp2400531

›Lieberthal AS, Carroll AE, et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013

›AAP clinical practice guideline; diagnostic criteria and antibiotic management framework

›https://publications.aap.org/pediatrics/article-lookup/doi/10.1542/peds.2012-3488

›Gaddey HL, Wright MT, Nelson TN. Otitis Media: Rapid Evidence Review. American Family Physician. 2019

›Practical clinical summary with management pearls

›https://pubmed.ncbi.nlm.nih.gov/31524361

›Systematic reviews and meta-analyses

›Darlison P, et al. Decongestants and Antihistamines for Acute Otitis Media in Children. Cochrane Database. 2025

›Confirms no benefit of decongestants or antihistamines in AOM

›https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD015839.pub2/full

›Ranakusuma RW, et al. Systemic Corticosteroids for Acute Otitis Media in Children. Cochrane Database. 2018

›No significant benefit of systemic corticosteroids

›https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012289.pub2/full

›Uhari M, Mantysaari K, Niemela M. A Meta-Analytic Review of the Risk Factors for Acute Otitis Media. Clin Infect Dis. 1996

›Quantified risk factors including daycare, family history, and smoking

›https://pubmed.ncbi.nlm.nih.gov/8783714

›Imaging and complications references

›Agarwal M, Juliano AF, et al. ACR Appropriateness Criteria Inflammatory Ear Disease. JACR. 2025

›Guidance on imaging selection for complicated AOM and mastoiditis

›https://linkinghub.elsevier.com/retrieve/pii/S1546-1440(25)00132-2

›Bridwell RE, Koyfman A, Long B. High Risk and Low Prevalence Diseases: Acute Mastoiditis. Am J Emerg Med. 2024

›Emergency medicine perspective on mastoiditis recognition and management

›https://pubmed.ncbi.nlm.nih.gov/38368849

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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