Otitis media

Acute otitis media (AOM) is a painful type of ear infection. It occurs when the area behind the eardrum called the middle ear becomes inflamed and infected.

The following behaviors in children often mean they have AOM:

  • fits of fussiness and intense crying (in infants)
  • clutching the ear while wincing in pain (in toddlers)
  • complaining about a pain in the ear (in older children)

What Are the Symptoms of Acute Otitis Media

Infants and children may have one or more of the following symptoms:

  • crying
  • irritability
  • sleeplessness
  • pulling on the ears
  • ear pain
  • a headache
  • neck pain
  • a feeling of fullness in the ear
  • fluid drainage from the ear
  • a fever
  • vomiting
  • diarrhea
  • irritability
  • a lack of balance
  • hearing loss

What Causes Acute Otitis Media?

The eustachian tube is the tube that runs from the middle of the ear to the back of the throat. An AOM occurs when your child’s eustachian tube becomes swollen or blocked and traps fluid in the middle ear. The trapped fluid can become infected. In young children, the eustachian tube is shorter and more horizontal than it is in older children and adults. This makes it more likely to become infected.

The eustachian tube can become swollen or blocked for several reasons:

  • allergies
  • a cold
  • the flu
  • a sinus infection
  • infected or enlarged adenoids
  • cigarette smoke
  • drinking while laying down (in infants)

Who Is at Risk for Acute Otitis Media?

The risk factors for AOM include:

  • being between 6 and 36 months old
  • using a pacifier
  • attending daycare
  • being bottle fed instead of breastfed (in infants)
  • drinking while laying down (in infants)
  • being exposed to cigarette smoke
  • being exposed to high levels of air pollution
  • experiencing changes in altitude
  • experiencing changes in climate
  • being in a cold climate
  • having had a recent cold, flu, sinus, or ear infection

Genetics also plays a role in increasing your child’s risk of AOM.

How Is Acute Otitis Media Diagnosed?

Your child’s doctor may use one or more of the following methods to diagnose AOM:


Your child’s doctor uses an instrument called an otoscope to look into your child’s ear and detect:

  • redness
  • swelling
  • blood
  • pus
  • air bubbles
  • fluid in the middle ear
  • perforation of the eardrum

During a tympanometry test, your child’s doctor uses a small instrument to measure the air pressure in your child’s ear and determine if the eardrum is ruptured.


During a reflectometry test, your child’s doctor uses a small instrument that makes a sound near your child’s ear. Your child’s doctor can determine if there’s fluid in the ear by listening to the sound reflected back from their ear.

Hearing Test

Your doctor may perform a hearing test to determine if your child is experiencing hearing loss. Otitis media is a group of inflammatory diseases of the middle ear. The two main types areacute otitis media (AOM) and otitis media with effusion (OME).AOM is an infection of abrupt onset that usually presents with ear pain. In young children this may result in pulling at the ear, increased crying, and poor sleep. Decreased eating and a fever may also be present. OME is typically not associated with symptoms. Occasionally a feeling of fullness is described. It is defined as the presence of non-infectious fluid in the middle ear for more than three months. Chronic suppurative otitis media (CSOM) is middle ear inflammation of greater than two weeks that results in episodes of discharge from the ear. It may be a complication of acute otitis media. Pain is rarely present.[4] All three may be associated withhearing loss.The hearing loss in OME, due to its chronic nature, may affect a child’s ability to learn.

The cause of AOM is related to childhood anatomy and immune function. Either bacteria or viruses may be involved. Risk factors include exposure to smoke, use of pacifiers, and attending daycare. It occurs more commonly in those who are Native American or who haveDown syndrome. OME frequently occurs following AOM and may be related to viral upper respiratory infections, irritants such as smoke, or allergies. Looking at the eardrum is important for making the correct diagnosis.Signs of AOM include bulging or a lack of movement of the tympanic membrane from a puff of air. New discharge not related to otitis externa also indicates the diagnosis.

A number of measures decrease the risk of otitis media including pneumococcal and influenza vaccination, exclusive breastfeeding for the first six months of life, and avoiding tobacco smoke In those with otitis media with effusion antibiotics do not generally speed recovery.The use of pain medications for AOM is important.This may includeparacetamol (acetaminophen), ibuprofenbenzocaine ear drops, or opioids.[3] In AOM, antibiotics may speed recovery but may result in side effects.[8] Antibiotics are often recommended in those with severe disease or under two years old. In those with less severe disease they may only be recommended in those who do not improve after two or three days.[6]The initial antibiotic of choice is typically amoxicillin. In those with frequent infectionstympanostomy tubes may decrease recurrence.[3]

Signs and symptoms

Otitis media.

An integral symptom of acute otitis media is ear pain; other possible symptoms include fever, and irritability (in infants). Since an episode of otitis media is usually precipitated by an upper respiratory tract infection (URTI), there often are accompanying symptoms like cough and nasal discharge.[12]

Discharge from the ear can be caused by acute otitis media with perforation of the ear drum, chronic suppurative otitis media, tympanostomy tube otorrhea, or acute otitis externa. Trauma, such as a basilar skull fracture, can also lead to discharge from the ear due to cerebral spinal drainage from the brain and its covering (meninges).


The common cause of all forms of otitis media is dysfunction of the Eustachian tube.[13]This is usually due to inflammation of the mucous membranes in the nasopharynx, which can be caused by a viral URIstrep throat, or possibly by allergies.[14] Because of the dysfunction of the Eustachian tube, the gas volume in the middle ear is trapped and parts of it are slowly absorbed by the surrounding tissues, leading to negative pressure in the middle ear. Eventually the negative middle-ear pressure can reach a point where fluid from the surrounding tissues is sucked in to the middle ear’s cavity (tympanic cavity), causing a middle-ear effusion. This is seen as a progression from a Type A tympanogram to a Type C to a Type B tympanogram.

By reflux or aspiration of unwanted secretions from the nasopharynx into the normally sterile middle-ear space, the fluid may then become infected — usually with bacteria. The virus that caused the initial URI can itself be identified as the pathogen causing the infection.[14]



Perforation of the right tympanic membrane resulting from a previous severe acute otitis media

As its typical symptoms overlap with other conditions, such as acute external otitis, clinical history alone is not sufficient to predict whether acute otitis media is present; it has to be complemented by visualization of the tympanic membrane.[15][16] Examiners use a pneumatic otoscope with a rubber bulb attached to assess the mobility of the tympanic membrane.

Acute otitis media in children with moderate to severe bulging of the tympanic membrane or new onset of otorrhea (drainage) is not due to external otitis. Also, the diagnosis may be made in children who have mild bulging of the ear drum and recent onset of ear pain (less than 48 hours) or intense erythema (redness) of the ear drum.

To confirm the diagnosis, middle-ear effusion and inflammation of the eardrum have to be identified; signs of these are fullness, bulging, cloudiness and redness of the eardrum.[12] It is important to attempt to differentiate between acute otitis media and otitis media with effusion (OME), as antibiotics are not recommend for OME.[12] It has been suggested that bulging of the tympanic membrane is the best sign to differentiate AOM from OME [17]

Viral otitis may result in blisters on the external side of the tympanic membrane, which is called bullous myringitis (myringa being Latin for “eardrum”).[18]

However, sometimes even examination of the eardrum may not be able to confirm the diagnosis, especially if the canal is small. If wax in the ear canal obscures a clear view of the eardrum it should be removed using a blunt cerumen curette or a wire loop. Also, an upset young child’s crying can cause the eardrum to look inflamed due to distension of the small blood vessels on it, mimicking the redness associated with otitis media.

Acute otitis media

The most common bacteria isolated from the middle ear in AOM are Streptococcus pneumoniaeHaemophilus influenzaeMoraxella catarrhalis,[12] and Staphylococcus aureus.[19]

Otitis media with effusion

Otitis media with effusion (OME), also known as serous otitis media (SOM) or secretory otitis media (SOM), and commonly referred to as glue ear,[20] is a collection of effusion (fluid) that occurs in the middle-ear space due to the negative pressure produced by dysfunction of the Eustachian tube. This can occur purely from a viral URI or bacterial infection, or it can precede and/or follow acute bacterial otitis media.[21] Fluid in the middle ear frequently causes conductive hearing impairment but only when it interferes with the normal vibration of the eardrum by sound waves. Over weeks and months, middle-ear fluid can become very thick and glue-like, which increases the likelihood of its causing conductive hearing impairment.

Early-onset OME is associated with feeding of infants while lying down, early entry into group child care, parental smoking, lack, or too short a period of breastfeeding and greater amounts of time spent in group child care, particularly those with a large number of children, increases the incidences and duration of OME in the first two years of life.[22]

Chronic suppurative otitis media

Chronic suppurative otitis media, incorrectly called chronic otitis media or chronic ear infection, involves a hole in the tympanic membrane and active bacterial infection within the middle-ear space for several weeks or more. There may be enough pus that it drains to the outside of the ear (otorrhea), or the pus may be minimal enough to only be seen on examination using the otoscope or, more effectively, with a binocular microscope. This disease is much more common in persons with poor Eustachian tube function and very common in certain races such as Native North Americans. Hearing impairment often accompanies this disease.

It is a primary cause of hearing loss that newly develops in children. An ear wick may be effective or, if not, antibiotics.[23]

Adhesive otitis media

Adhesive otitis media occurs when a thin retracted ear drum becomes sucked into the middle-ear space and stuck (i.e., adherent) to theossicles and other bones of the middle ear.

There are several subtypes of OM, as follows:

  • Acute OM (AOM)
  • OM with effusion (OME)
  • Chronic suppurative OM
  • Adhesive OM

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

OME often follows an episode of AOM. Symptoms that may be indicative of OME include the following:

  • Hearing loss
  • Tinnitus
  • Vertigo
  • Otalgia

Chronic suppurative otitis media is a persistent ear infection that results in tearing or perforation of the eardrum.

Adhesive otitis media occurs when a thin retracted ear drum becomes sucked into the middle ear space and stuck.


OME does not benefit from antibiotic treatment. Therefore, it is critical for clinicians to be able to distinguish normal middle ear status from OME or AOM. Doing so will avoid unnecessary use of antibiotics, which leads to increased adverse effects of medication and facilitates the development of antimicrobial resistance.


Pneumatic otoscopy remains the standard examination technique for patients with suspected OM. In addition to a carefully documented examination of the external ear and tympanic membrane (TM), examining the entire head and neck region of patients with suspected OM is important.

Every examination should include an evaluation and description of the following four TM characteristics:

  • Color – A normal TM is a translucent pale gray; an opaque yellow or blue TM is consistent with middle ear effusion (MEE)
  • Position – In AOM, the TM is usually bulging; in OME, the TM is typically retracted or in the neutral position
  • Mobility – Impaired mobility is the most consistent finding in patients with OME
  • Perforation – Single perforations are most common

Otitis media is an infection of the middle ear that causes inflammation (redness and swelling) and a build-up of fluid behind the eardrum.

Anyone can develop a middle ear infection but infants between six and 15 months old are most commonly affected.

It’s estimated that around one in every four children experience at least one middle ear infection by the time they’re 10 years old.

Symptoms of a middle ear infection

In most cases, the symptoms of a middle ear infection (otitis media) develop quickly and resolve in a few days. This is known as acute otitis media. The main symptoms include:

  • earache
  • a high temperature (fever)
  • being sick
  • a lack of energy
  • slight hearing loss – if the middle ear becomes filled with fluid, hearing loss may be a sign of glue ear, also known as otitis media with effusion

In some cases, a hole may develop in the eardrum (perforated eardrum) and pus may run out of the ear. The earache, which is caused by the build-up of fluid stretching the eardrum, then resolves.

Signs in young children

As babies are unable to communicate the source of their discomfort, it can be difficult to tell what’s wrong with them. Signs that a young child might have an ear infection include:

  • pulling, tugging or rubbing their ear
  • irritability, poor feeding or restlessness at night
  • coughing or a runny nose
  • diarrhoea
  • unresponsiveness to quiet sounds or other signs of difficulty hearing, such as inattentiveness
  • loss of balance

When to seek medical advice

Most cases of otitis media pass within a few days, so there’s usually no need to see your GP.

However, see your GP if you or your child have:

  • symptoms showing no sign of improvement after two or three days
  • a lot of pain
  • a discharge of pus or fluid from the ear – some people develop a persistent and painless ear discharge that lasts for many months, known as chronic suppurative otitis media
  • an underlying health condition, such as cystic fibrosis or congenital heart disease, which could make complications more likely
  • Acute otitis media

  • Acute otitis media, myringitis bullosa

  • Chronic otitis media (otitis media chronica mesotympanalis)

  • Otitis media chronica mesotympanalis

  • Otitis media chronica mesotympanalis

  • Otitis media chronica mesotympanalis



Long-term antibiotics, while they decrease rates of infection during treatment, have an unknown effect on long-term outcomes such ashearing loss.[24] This method of prevention has been associated with emergence of antibiotic-resistant otitic bacteria. They are thus not recommended.[12]

Pneumococcal conjugate vaccines when given during infancy decrease rates of acute otitis media by 6%–7% and, if implemented broadly, would have a significant public health benefit.[12][25][needs update] Influenza vaccine is recommended annually.[12]

Risk factors such as season, allergy predisposition and presence of older siblings are known to be determinants of recurrent otitis media and persistent middle-ear effusions (MEE).[26] History of recurrence, environmental exposure to tobacco smoke, use of daycare, and lack of breastfeeding have all been associated with increased risk of development, recurrence, and persistent MEE.[27][28] Thus, cessation of smoking in the home should be encouraged, daycare attendance should be avoided or daycare facilities with the fewest attendees should be recommended, and breastfeeding should be promoted.

There is some evidence that breastfeeding for the first year of life is associated with a reduction in the number and duration of OM infections. Pacifier use, on the other hand, has been associated with more frequent episodes of AOM.

Evidence does not support zinc supplementation as an effort to reduce otitis rates except maybe in those with severe malnutrition such asmarasmus.


Oral and topical pain killers are effective to treat the pain caused by otitis media. Oral agents include ibuprofen, paracetamol(acetaminophen), and opiates. Topical agents shown to be effective include antipyrine and benzocaine ear drops.[33] Decongestants andantihistamines, either nasal or oral, are not recommended due to the lack of benefit and concerns regarding side effects.[34] Half of cases ofear pain in children resolves without treatment in three days and 90% resolves in seven or eight days.[35]


It is important to weigh the benefits and harms before using antibiotics for acute otitis media. As over 80% of acute episodes settle without treatment, about 20 children must be treated to prevent one case of ear pain, 33 children to prevent one perforation, and 11 children to prevent one opposite-side ear infection. For every 14 children treated with antibiotics, one child has an episode of either vomiting, diarrhea or a rash.[36][needs update] If pain is present, treatment to reduce it should be initiated.

  • Antibiotics should be prescribed for severe bilateral or unilateral disease in all infants and children with severe signs and symptoms, such as moderate to severe ear pain and high fever.
  • For bilateral acute otitis media in infants younger than 24 months of age, without severe signs and symptoms, antibiotics should be prescribed.
  • When non-severe unilateral acute otitis media is diagnosed in young children either antibiotic therapy is given or observation with close follow-up based on joint decision making between parent(s)/caregiver in infants 6 to 23 months of age. If the child worsens or fails to improve in 2 to 3 days antibiotics should be administered.
  • Children 24 months or older with non-severe disease can have either antibiotics or observation.

The first line antibiotic treatment, if warranted, is amoxicillin.[12] If there is resistance or use of amoxicillin in the last 30 days thenamoxicillin-clavulanate or another penicillin derivative plus beta lactamase inhibitor is recommended.[12] Taking amoxicillin once a day may be as effective as twice[37] or three times a day. While less than 7 days of antibiotics have less side effects, more than seven days appear to be more effective.[38] If there is no improvement after 2–3 days of treatment a change in therapy may be considered.[12]

A treatment option for chronic suppurative otitis media with discharge is topical antibiotics. A Cochrane review found that topical quinolone antibiotics can improve discharge better than oral antibiotics.[39] Safety is not really clear.[39]

Tympanostomy tube

Tympanostomy tubes (also called “grommets”) are recommended in those people who have three or more episodes of acute otitis media in 6 months or four or more in a year, with at least one episode or more attacks in the preceding 6 months.[12] In chronic cases with effusions, insertion of tympanostomy tube into the eardrum reduces recurrence rates in the 6 months after placement[40] but has little effect on long-term hearing.[41] A common complication of having a tympanostomy tube is otorrhea, which is a discharge from the ear.[42]

Oral antibiotics should not be used to treat uncomplicated acute tympanostomy tube otorrhea.[42] Oral antibiotics are not a sufficient response to bacteria that cause this condition and have significant side effects including increased risk of opportunistic infection.[42] In contrast, topical antibiotic eardrops can treat this condition.[42]

Alternative medicine

Complementary and alternative medicine is not recommended for otitis media with effusion because there is no evidence of benefit.[21] Anosteopathic manipulation technique called the Galbreath technique[43] was evaluated in one randomized controlled clinical trial; one reviewer concluded that it was promising, but a 2010 evidence report found the evidence inconclusive.[44]

How middle ear infections are treated

Most ear infections clear up within three to five days and don’t need any specific treatment. If necessary, paracetamol or ibuprofen should be used to relieve pain and a high temperature.

Make sure any painkillers you give to your child are appropriate for their age. Read more about giving your child painkillers.

Antibiotics aren’t routinely used to treat middle ear infections, although they may occasionally be prescribed if symptoms persist or are particularly severe.

Read more about treating middle ear infections.

What causes middle ear infections?

Most middle ear infections occur when an infection such as a cold, leads to a build-up of mucus in the middle ear and causes the Eustachian tube (a thin tube that runs from the middle ear to the back of the nose) to become swollen or blocked.

This mean mucus can’t drain away properly, making it easier for an infection to spread into the middle ear.

An enlarged adenoid (soft tissue at the back of the throat) can also block the Eustachian tube. The adenoid can be removed if it causes persistent or frequent ear infections. Read more about removing adenoids.

Younger children are particularly vulnerable to middle ear infections as:

  • the Eustachian tube is smaller in children than in adults
  • a child’s adenoids are relatively much larger than an adults

Certain conditions can also increase the risk of middle ear infections, including:

  • having a cleft palate – a type of birth defect where a child has a split in the roof of their mouth
  • having Down’s syndrome – a genetic condition that typically causes some level of learning disability and a characteristic range of physical features

Can middle ear infections be prevented?

It’s not possible to prevent middle ear infections, but there are some things you can do that may reduce your child’s risk of developing the condition. These include:

  • make sure your child is up-to-date with their routine vaccinations – particularly the pneumococcal vaccine and the DTaP/IPV/Hib (5-in-1) vaccine
  • avoid exposing your child to smoky environments (passive smoking)
  • don’t give your child a dummy once they’re older than six to 12 months old
  • don’t feed your child while they’re lying flat on their back
  • if possible, feed your baby with breast milk rather than formula milk


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