1. Make the diagnosis of otitis media (OM) only after good visualization of the eardrum (i.e., wax must be removed), and when sufficient changes are present in the eardrum, such as bulging or distorted light reflex (i.e., not all red eardrums indicate OM).

  2. Include pain referred from other sources in the differential diagnosis of an earache (eg. Tooth abscess, trigeminal neuralgia, TMJ dysfunction, pharyngitis, etc.).

  3. Consider serious causes in the differential diagnosis of an earache (eg. tumors, temporal arteritis, mastoiditis).

  4. In the treatment of otitis media, explore the possibility of not giving antibiotics, thereby limiting their use (e.g., through proper patient selection and patient education because most otitis media is of viral origin), and by ensuring good follow-up (e.g., reassessment in 48 hours).

  5. Make rational drug choices when selecting antibiotic therapy for the treatment of otitis media. (Use first-line agents unless given a specific indication not to.)

  6. In patients with earache (especially those with otitis media), recommend appropriate pain control (oral analgesics).

  7. In a child with a fever and a red eardrum, look for other possible causes of the fever (i.e., do not assume that the red ear is causing the fever). *See the key features on fever

  8. Test children with recurrent ear infections for hearing loss.


  • AOM

    • Complications (rare, risk in pneumococcus and <2yo)

      • Acute mastoiditis (pain/swelling over mastoid bone)

      • Acute facial nerve palsy - associated with temporal bone inflammation

      • Sixth CN palsy (failure of ipsilateral eye abduction) due to petrous bone inflammation or infection (Gradenigo's syndrome)

      • Labyrinthitis

      • Venous sinus thrombosis

      • Meningitis

  • Middle ear

    • Otitis media with effusion (usually nasal infection or allergy)

    • Trauma (TM perforation/foreign body)

    • Cholesteatoma*

    • Tumor*

  • Otitis externa (normal TM, painful tender outer ear)

    • Treatment

      • Keep dry (Avoid water sports x 7-10d)

      • Clean ear canal

      • Analgesia

      • Mild, Buro-Sol 2-3 drops TID-QID

      • Moderate, Ciprodex 4 drops TID

      • If perforated consider systemic antibiotics.

    • r/o necrotizing/malignant otitis externa (elderly, diabetic, immunocompromised, otalgia despite antibiotics, granulation tissue in ear canal)

      • ESR, CRP, osteomyelitis on CT/MRI

      • Ciprofloxacin 750 mg PO BID PLUS Ciprodex 4 drops BID x 4-8w

  • Herpes zoster (Ramsay Hunt syndrome)

  • Secondary otalgia

    • Sinusitis / Stomatitis / Parotitis / Pharyngitis

    • Dental infection / abscess

    • TMJ dysfunction syndrome

    • Auricular lymphadenopathy

    • Facial nerve palsy

    • Trigeminal neuralgia

    • Temporal arteritis*


AOM characterized by acute otalgia, middle ear fluid with inflammation of middle ear (bulging, erythematous, yellow/cloudy) or rupture

  • Impaired mobility is most sensitive and specific (95%, 85%)

  • Bulging TM low sensitivity but high specificity (51%, >97%)

  • Acute perforation with purulent discharge (otorrhea) in the context of AOM supports bacterial cause

  • S pneumoniae is the predominant pathogens, M catarrhalis and H influenzae usually resolve spontaneously


  • Smoking exposure

  • Upper respiratory tract infection

  • Daycare (sick contacts)

  • Bottlefeed

  • Pacifier

  • Personal history, family history of AOM


  • Immediate therapy if < 6months of age

    • Send to ER if <3 months old with T>38, suspect meningitis or mastoiditis, toxic looking

  • Healthy children ≥6 months with mild disease, consider:

    • Watchful waiting, and reassess in 24 to 48h (return if worsens anytime within 48h)

    • Antimicrobial prescription to start course if child does not improve

      • Acetaminophen 10-15mg/kg/dose q4-6h (max 75mg/kg/day)

      • Ibuprofen 5-10mg/kg/dose q6-8h (max 40mg/kg/day)

  • Bulging TM, febrile (≥39°C), moderately systemically ill, or severe otalgia, or significantly ill for 48h should be treated with antimicrobials

First-line treatment (no penicillin allergy)

  • Pediatric: Amoxicillin 75 to 90mg/kg/day (max 2000mg) ÷BID

  • Adults: Amoxicillin 500mg PO TID x 5-10d (can use 1g PO TID if high risk) in adults

  • Penicillin allergy

    • Non-anaphylactic: Cefuroxime 30 mg/kg/day ÷ BID-TID

    • Anaphylactic: Clarithromycin 15mg/kg/day PO ÷ BID x5-10d or Azithromycin 10mg/kg PO day 1, then 5mg/kg PO x 4d

  • Second-line (no response x 2-3d or recent amoxicillin use in 30 days)

    • Amoxicillin-clavulanate (7:1 formulation, 400 mg/5 mL suspension) 45 to 60 mg/kg/day ÷ TID (max 500mg PO TID) x 10d

      • Adults: 875/125mg BID or 2000/125mg BID x 10 days

    • Ceftriaxone 50 mg/kg IM/IV daily (max 1000mg) x 3 days

Duration of treatment

  • 5 days in children ≥2 years of age with mild/uncomplicated disease

  • 10 days if <2years of age, recurrent AOM or perforated TM

Special circumstances

  • Otitis-conjunctivitis syndrome - AOM with purulent conjunctivitis (usually M catarrhalis and H influenzae are common pathogens)

    • Treat with Amoxicillin-clavulanate or 2nd gen cephalosporin (eg. cefuroxime-axetil)

  • Allergy to penicillin

    • Non-anaphylactic: Cephalosporin (cefprozil 30mg/kg/d divided BID, cefuroxime-axetil)

    • Anaphylactic: Macrolide (azithromycin, clarithromycin 15mg/kg/d divided BID ) or clindamycin

  • ENT referral (Consider Audiology if recurrent episodes r/o hearing loss)

    • Tympanostomy Tube Indications

      • Recurrent AOM (3x/6 months or 4x/1 year) with middle ear effusion at the time of evaluation

      • Chronic OME >3 months

        • With risk of speech/learning problems

        • Bilateral OME with Hearing loss

        • Symptoms attributable with OME (vestibular problems, poor school performance, behavioural problems, ear discomfort)

      • Note: Water precautions should not be encouraged routinely in patients with tympanostomy tubes

      • Note: Topical antibiotic eardrops (Eg. Ciprofloxacin (Ciprodex) = 4 drops BID x 5 days) without oral antibiotics should be prescribed for children with uncomplicated acute tympanostomy tube otorrhea

    • AOM resistant to second-line antibiotics

    • Perforated TM non-resolved after 6w