Clinical Practice Guidelines

Otitis Media

Diagnosis and Management of Acute Otitis Media

(Endorsed, July 2013)

The guideline, The Diagnosis and Management of Otitis Media, was developed by the American Academy of Pediatrics and endorsed by the American Academy of Family Physicians. It applies to otherwise healthy children 6 months through 12 years of age.

Key Recommendations

Diagnosis

  • The diagnosis of acute otitis media (AOM) should be made in children who present with moderate to severe bulging of the tympanic membrane (TM) or new onset of ottorhea not due to acute otitis externa or mild bulging of the TM and recent (less than 48 hours) onset of ear pain or intense erythema of the TM.
  • AOM should not be diagnosed in children who do not have middle ear effusion (MEE) (based on pneumatic otoscopy and/or tympanometry).

Management

  • Pain should be assessed in children diagnosed with AOM and, if present, the clinician should recommend treatment to reduce pain.
  • Antibiotic therapy should be prescribed for AOM (bilateral or unilateral) in children 6 months and older with severe signs or symptoms (i.e., moderate or severe otalgia or otalgia for at least 48 hours or temperature 39°C [102.2°F] or higher).
  • Antibiotic therapy should be prescribed for bilateral AOM in children 6 months through 23 months of age without severe signs or symptoms.
  • For nonsevere unilateral AOM in children 6 months to 23 months of age, or nonsevere AOM (either unilateral or bilateral) in children 24 months of age or older, antibiotic therapy should be prescribed or observation offered with close follow-up. When observation is used, a mechanism must be in place to ensure follow-up and initiation of antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms.
  • Amoxicillin should be prescribed for AOM when a decision to treat with antibiotics has been made unless the child has received amoxicillin in the past 30 days, the child has concurrent purulent conjunctivitis, the child is allergic to penicillin, or the child has a history of recurrent AOM unresponsive to amoxicillin.
  • Prophylactic antibiotics should not be prescribed to reduce the frequency of episodes of AOM in children with recurrent AOM. Tympanostomy tubes may be offered for recurrent AOM (3 episodes in 6 months or 4 episodes in 1 year with 1 episode in the preceding 6 months).

Otitis Media With Effusion

(Jointly Developed by the AAFP, February 2004)

The guideline, Otitis Media with Effusion, was jointly developed by the American Academy of Family Physicians, the American Academy of Otolaryngology-Head and Neck Surgeons, and the American Academy of Pediatrics.

Key Recommendations

  • Pneumatic otoscopy should be used as the primary diagnostic method for otitis media with effusion (OME). Tympanometry can be used to confirm the diagnosis.
  • The laterality, duration of effusion, and presence and severity of associated symptoms should be documented at each assessment of the child with OME.
  • The child with OME who is at increased risk for speech, language, or learning problems should be promptly evaluated for hearing, speech, and need for intervention.
  • The child with OME who is not at increased risk should be managed with watchful waiting for 3 months from the date of effusion onset (if known), or from the date of diagnosis (if onset is unknown). The child should then be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or stuctural abnormalities of the eardrum or middle ear are suspected.
  • Hearing testing should be done when OME persists for ≥ 3 months, or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME.
  • When a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure.
  • Antihistamines and decongestants are ineffective for OME and should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management.

These guidelines are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These guidelines are only one element in the complex process of improving the health of America. To be effective, the guidelines must be implemented.