Paeds · ent-hearing-and-oral-health
Acute otitis media
Also known as Acute middle-ear infection · Acute suppurative otitis media · Ear infection
Fellowship guide to acute otitis media (AOM): the acute suppurative inflammation of the middle-ear mucosa behind an intact tympanic membrane, diagnosed from a bulging eardrum or new otorrhea rather than redness alone; the AAP three-part criteria; the Streptococcus pneumoniae, Haemophilus influenzae and Moraxella pathogens and the Eustachian-tube-dysfunction mechanism; severity grading and the age-and-laterality matrix that separates watchful waiting with a safety-net from immediate antibiotics; analgesia for every child; first-line high-dose amoxicillin 90 mg/kg/day twice daily with the penicillin-allergy pathway; the red flags of mastoiditis; recurrent AOM and grommet decisions; and the ANZ, UK and North American guideline differences.
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Target exams
Red flags
- A toxic, systemically unwell child, or a postauricular swelling, erythema or an ear pushed forwards and downwards — suspect acute mastoiditis, arrange urgent assessment and imaging, start intravenous antibiotics and involve ENT
- An infant under one month with fever and suspected AOM — do not manage as simple otitis; this child needs urgent septic workup and inpatient assessment
- Persistent or worsening otalgia, fever or systemic features at 48 to 72 hours despite appropriate analgesia — reassess, reconsider the diagnosis, and start or change antibiotics
- A bulging tympanic membrane with severe pain, vomiting, imbalance or neurological signs — consider an intracranial or labyrinthine complication and escalate
- AOM in a child with a cochlear implant, immunodeficiency or chronic suppurative ear disease — lower the threshold for antibiotics and specialist input
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Acute and infectious illness
- Common ear, nose and throat presentations
- Current 2026 PREP curriculum — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Acute and critical care
- Antimicrobial stewardship and evidence-based prescribing in general paediatrics
- Clinical Applications
- Acute paediatrics and infection
- Short Cases
- Acute assessment scenarios
- Communication and safety-netting scenarios
- 4. Professional skills and knowledge: Patient management
- 6. Acute and emergency care
- General Paediatrics: Recognises and manages common childhood infections
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Common ENT and infection presentations
- Clinical
- History and management planning
- Acute assessment and safety-netting
- General Pediatrics Content Outline — Domain 2: Emergency Medicine
- General Pediatrics Content Outline — Domain 5: Infectious Diseases
- General Pediatrics EPA: Manage common acute infections and prescribe safely
- Patient Care 1: History and Physical Examination
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Emergency and acute care
- Medical Knowledge 1: Clinical Knowledge
- Systems-Based Practice: antibiotic stewardship
- Medical Expert
- Communicator
- Collaborator
- Scholar
- Pediatrics: Core EPA — Manage common paediatric infections with antimicrobial stewardship
Overview & Definition
Picture the fourteen-month-old who has had a cold for two days and now wakes at night screaming, tugging at her ear, with a fever. She is miserable but not toxic, and when you look in her ear the eardrum bulges towards you, is a dull red-yellow, and does not move when you puff air into the speculum. That picture — an acute, painful, bulging eardrum after a viral prodrome in a young child — is acute otitis media, and recognising the bulge (not the redness) is what separates a confident diagnosis from an over-called one. [1] [2]
Acute otitis media is an acute, infective inflammation of the middle-ear cleft — the mucosa lining the tympanic cavity, mastoid antrum and Eustachian tube — accompanied by a middle-ear effusion. The term implies the eardrum is intact at the moment of diagnosis; if the drum perforates, the child develops ear discharge (otorrhoea), which is itself a diagnostic and therapeutic milestone. It is one of the commonest reasons a young child is brought to medical care and prescribed an antibiotic, which is exactly why getting the diagnosis and the antibiotic decision right matters for both the individual child and antibiotic stewardship. [1] [3]
Why this matters at fellowship level is that AOM sits at the intersection of three things examiners test: a strict diagnostic rule (the bulging eardrum), a nuanced treatment decision (the age-and-laterality matrix), and a red-flag mindset (mastoiditis and the toxic child). The evidence base is mature — antibiotics help a little, on average, and carry a real cost — so the modern skill is selective, evidence-based prescribing combined with genuine safety-netting, not reflex treatment of every red eardrum. [6] [3]
References11ShowHide
- [1]Lieberthal AS, et al. The diagnosis and management of acute otitis media. Pediatrics, 2013.PMID 23439909
- [2]Schilder AG, et al. Otitis media. Nat Rev Dis Primers, 2016.PMID 27604644
- [3]Coker TR, et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: a systematic review. JAMA, 2010.PMID 21081729
- [4]Hoberman A, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med, 2011.PMID 21226576
- [5]Tähtinen PA, et al. A placebo-controlled trial of antimicrobial treatment for acute otitis media. N Engl J Med, 2011.PMID 21226577
- [6]Venekamp RP, et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev, 2015.PMID 26099233
- [7]Foxlee R, et al. Topical analgesia for acute otitis media. Cochrane Database Syst Rev, 2006.PMID 16856108
- [8]Casey JR, Pichichero ME Changes in frequency and pathogens causing acute otitis media in 1995-2003. Pediatr Infect Dis J, 2004.PMID 15361720
- [9]Fortanier AC, et al. Pneumococcal conjugate vaccines for preventing otitis media. Cochrane Database Syst Rev, 2014.PMID 24696098
- [10]Venekamp RP, et al. Grommets (ventilation tubes) for recurrent acute otitis media in children. Cochrane Database Syst Rev, 2018.PMID 29741289
- [11]Anne S, et al. Medical Versus Surgical Treatment of Pediatric Acute Mastoiditis: A Systematic Review. Laryngoscope, 2019.PMID 30284265