Pediatrics & Otolaryngology & Family Medicine
Acute otitis media (AOM)
Acute otitis media (AOM) is an acute infection of the middle ear - the enclosed cavity bounded by the eardrum at the front, the mastoid at the back and the Eustachian tube at the bottom - constituting the most frequent bacterial infection in children and the leading cause of antibiotic prescriptions in pediatrics in industrialized countries. It affects around 80 % of children under the age of 3, with peak incidence between 6 and 24 months, coinciding with the period of daycare attendance, incomplete immunological maturation and maximum tubal vulnerability. The pathophysiology is a virtually constant progression from a viral infection of the upper respiratory tract (rhinovirus, respiratory syncytial virus, influenza), which causes inflammation and dysfunction of the Eustachian tube - the canal that ensures ventilation and drainage of the middle ear - to bacterial superinfection of the obstructed airspace of the tympanic case, with bacteria colonizing the nasopharynx, taking advantage of the tubal obstruction to ascend into the middle ear. The three main bacterial agents are Streptococcus pneumoniae (30 to 40 % of cases), Haemophilus influenzae non-typable (30 to 40 %) and Moraxella catarrhalis (10 to 15 %). The diagnosis is clinical and otoscopic—diagnosis confirmation relies on direct visualization of a bulging, hyperemic, and opaque tympanic membrane, with loss of the light reflex. The main therapeutic challenge is to define whether antibiotic therapy is necessary—spontaneous resolution occurring in 80 to 90 %of children over 2 years of age with non-severe AOM—or if close monitoring without antibiotics is appropriate, as part of a strategy to preserve antibiotic resistance.
Pathophysiology and risk factors
- Central role of the Eustachian tube: Upper airway viral infection -> inflammation of the nasopharyngeal mucosa -> edema and tubal obstruction -> negative pressure in the tympanic cavity -> aspiration of nasopharyngeal secretions containing pathogenic bacteria -> bacterial multiplication in a closed, unventilated environment -> suppuration -> bulging, hyperemic, and painful eardrum
- Child Anatomical Vulnerability Eustachian tube is shorter, more horizontal, less rigid, and opens less effectively during swallowing than in adults, explaining the peak prevalence between 6 months and 3 years. As the child grows and the tube lengthens and becomes more oblique, the frequency of OMAs (otitis media acute) spontaneously decreases.
- Primary risk factors: Attending daycare (risk x 2-3 - increased exposure to viruses and bacteria) + bottle feeding in a reclined position (milk reflux into the eustachian tube) + passive smoking (impairment of tubal mucociliary transport) + formula feeding vs. breastfeeding (breast milk protects via secretory IgA and macrophages) + family history of recurrent AOM + cleft palate (congenital tubal dysfunction) + immunosuppression
Diagnostics — Clinical and Otoscopic Criteria
- Functional signs Acute unilateral ear pain (young child who cannot verbalize pain pulls at ear + cries + is irritable + sleeps poorly + refuses to feed or eat due to worsening pain with swallowing) + fever (present in 50 to 75 % of cases — but otitis media can exist without fever) + temporary hearing loss + sometimes purulent otorrhea if spontaneous tympanic membrane perforation (paradoxically favorable sign — pain is often relieved) + absence of tragus pain (unlike external otitis)
- Otoscopy — positive diagnostic criteria: Bulging eardrum (convex towards the canal) + or opaque + hyperemic + with loss of the light reflex and normal landmarks + or purulent effusion visible behind the eardrum → simultaneous presence of effusion AND acute inflammation of the eardrum = certain acute otitis media + pneumatic otoscopy (eardrum mobility test under pressure) improves diagnostic accuracy (reduced mobility = effusion) + tympanometry (flat curve = type B) confirms effusion
- OMA certain vs probable vs otitis media with effusion ACUTE OTITIS MEDIA (AOM) certain: bulging + hyperemic + opaque tympanic membrane + fever + ear pain + PROBABLE AOM: slightly pink or opaque tympanic membrane + mild changes without frank bulging + OTITIS MEDIA WITH EFFUSION (OME): non-inflamed tympanic membrane + effusion without acute signs + no fever or ear pain → do not treat with antibiotics
ℹ️
The distinction between acute otitis media (AOM) and otitis media with effusion (OME—effusion without acute inflammation) is fundamental because their treatments differ radically: AOM may warrant antibiotics depending on age and severity criteria, whereas OME should never be treated with antibiotics (no demonstrated benefit + increased resistance). The pneumatic otoscope is the most effective tool for this distinction—to be used systematically in children with ear pain.
Therapeutic decision — who to treat with antibiotics?
| Clinical situation | Therapeutic recommendation | Justification |
|---|---|---|
| Infant < 6 months with certain or probable acute otitis media | Systemic antibiotic therapy from the outset, without delay + hospitalization if general condition is altered or temperature is high | High risk of serious complications (meningitis + mastoiditis) + immune immaturity + less frequent spontaneous resolution in this age group |
| Child 6 months to 2 years with definite bilateral otitis media | Empirical antibiotic therapy + amoxicillin 80–90 mg/kg/day in 2 doses × 10 days | Bilateral OMA is associated with a higher risk of spontaneous resolution and complications + the 2013 AAP and 2016 SCP recommendations advocate for upfront antibiotic therapy. |
| Child 6 months to 2 years with severe unilateral OMA (fever ≥ 39°C or severe otalgia) | Empirical antibiotic therapy | Clinical severity → antibiotic therapy without delay for pain control and prevention of complications |
| Child 6 months to 2 years with unilateral, non-severe acute otitis media | Option 1: immediate antibiotic therapy + Option 2: active observation (watchful waiting) for 48–72 hours with deferred antibiotic prescription + if worsening or no improvement → start antibiotics | 80% % spontaneous resolution in children over 6 months with unilateral non-severe AOM + reduced antibiotic consumption without increased complications in randomized trials |
| Child ≥ 2 years old with non-severe acute otitis media (unilateral or bilateral) | Active observation (watchful waiting) recommended first-line + analgesia + delayed prescription given to parents if worsening | Spontaneous resolution in 80-90 % of cases + reduction of antibiotic side effects (diarrhea + candidiasis + allergy) + preservation of flora + reduction of antibiotic resistance |
| OMA with purulent otorrhea (perforation) | Empirical oral antibiotic therapy + local antibiotic ear drops (ciprofloxacin) if abundant discharge | Tympanic perforation indicates active bacterial AOM, and otorrhea facilitates access of topical antibiotics to the middle ear. |
| Recurrent OMA (≥ 3 episodes in 6 months or ≥ 4 in 12 months) | Focus on pediatric ENT for discussion of tympanostomy tubes (TT) + no long-term prophylactic antibiotics (not recommended) | Antimicrobial Treatments reduce the number of recurrent OMA episodes by 50-60% % whereas prophylactic antibiotic therapy exposes to resistance without clear benefit. |
Antibiotic therapy — choice and dosage
- Amoxicillin — first choice: 80 to 90 mg/kg/day orally in 2 divided doses × 10 days (child < 2 years) or × 5 to 7 days (child ≥ 2 years with non-severe OMA) + optimal pneumococcal coverage including penicillin-non-susceptible *Streptococcus pneumoniae* (PNSP) strains thanks to high doses + advantages: narrow spectrum + well-tolerated + inexpensive + available as syrup
- Amoxicillin-clavulanate (Clavulin®) — if failure at 48–72 hours or if recent antibiotic therapy (< 30 days): 90 mg/kg/day amoxicillin + 6.4 mg/kg/day clavulanate in 2 doses × 10 days + indicated for amoxicillin-resistant AOM (beta-lactamase-producing strains of'H. influenzae or M. catarrhalis) + more frequent digestive side effects (diarrhea)
- Ceftriaxone IM 50 mg/kg single dose (max 1 g) — if vomiting or true penicillin allergy: Very effective against pneumococcus + good option if the child cannot take orally + or if there is a documented penicillin allergy (check the type of allergy — penicillin-cephalosporin cross-reactivity rare < 1 %) + 3 consecutive days for refractory AOM
- Azithromycin or clarithromycin - in case of severe allergy to beta-lactams: azithromycin 10 mg/kg/day × 3 days (or 10 mg/kg D1 then 5 mg/kg D2–D5) + warning: high resistance of pneumococcus to macrolides in North America (20 to 40 %) → to be used only if proven allergy to beta-lactams
- Painkillers - Absolute priority: paracetamol 15 mg/kg every 4–6 hours (max 75 mg/kg/day) + ibuprofen 10 mg/kg every 6–8 hours (if ≥ 6 months) → pain management is as important as antibiotic treatment + analgesic ear drops (lidocaine otic — Otigo® + Auralgan®) → rapid relief but short duration of action + do not use if tympanic membrane is perforated
Complications
- Acute mastoiditis Extension of infection to mastoid cells -> postauricular pain + swelling + postauricular erythema + pinna displaced forward and downward + high fever -> ENT emergency + hospitalization + IV antibiotics + surgical drainage if subperiosteal abscess
- Meningitis: The most serious and frequent complication in infants, characterized by neck stiffness, bulging fontanelle, extreme irritability, and photophobia, indicates a neurological emergency requiring immediate hospitalization.
- Facial paralysis Extension of infection to the fallopian canal (bony canal of the facial nerve traversing the mastoid) → ipsilateral peripheral facial paralysis → ENT emergency
- Labyrinthitis Extension to the cochlea and vestibule → Vertigo + nausea + vomiting + sensorineural hearing loss → ENT emergency
- Cholesteatoma long-term complication of recurrent otitis media with tympanic retractions → formation of invasive keratinizing epithelium in the middle ear → progressive destruction of ossicles, mastoid, and facial canal → tympanoplasty surgery
Situations requiring urgent medical assessment
Go immediately to the pediatric emergency room if an ear infection is accompanied by swelling and redness behind the earlobe with the earlobe protruding forward (mastoiditis) + stiff neck + bulging fontanelle in an infant + facial paralysis + intense dizziness + or very high fever with altered general condition in a child under 6 months old — these signs indicate a complication of otitis media requiring urgent hospital care.
For the diagnosis of acute otitis media by otoscopy, the prescription of antibiotics according to age and severity criteria, and the follow-up of children with recurrent otitis, Clinique Omicron offers medical consultations at its service points in Quebec and via telemedicine. To make an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's physician assistants (PAs) and nurse practitioners (NPs) diagnose acute otitis media using otoscopy and a pneumatic otoscope, apply age and severity criteria to decide on antibiotic therapy or active surveillance, prescribe optimal-dose amoxicillin or amoxicillin-clavulanate depending on the context, ensure follow-up at 48–72 hours if active surveillance is chosen, and refer children with recurrent ear infections to pediatric ENT. Consultations are available at multiple service points in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The content of this page is provided for informational purposes only and does not substitute for the advice of a doctor or pediatrician. The diagnosis of acute otitis media requires an otoscopy performed by a trained healthcare professional—antibiotic treatment should not be prescribed without otoscopic diagnostic confirmation to prevent antibiotic overuse and the emergence of bacterial resistance.
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