Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Acute otitis media in children: Treatment

Jerome O Klein, MD
Stephen Pelton, MD
Section Editors
Morven S Edwards, MD
Glenn C Isaacson, MD, FAAP
Deputy Editor
Mary M Torchia, MD


Acute otitis media (AOM), also called purulent otitis media and suppurative otitis media, occurs frequently in children. It is the most common diagnosis for which they receive antibiotics [1,2].

The treatment of uncomplicated AOM will be reviewed here. The epidemiology, pathogenesis, diagnosis, complications, and prevention of AOM are discussed separately, as is otitis media with effusion (serous otitis media).

(See "Acute otitis media in children: Epidemiology, microbiology, clinical manifestations, and complications".)

(See "Acute otitis media in children: Diagnosis".)

(See "Acute otitis media in children: Prevention of recurrence".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Dec 05, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescribing rates for children and adolescents. JAMA 2002; 287:3096.
  2. Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings. JAMA 2009; 302:758.
  3. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013; 131:e964.
  4. Shaikh N, Hoberman A, Rockette HE, Kurs-Lasky M. Development of an algorithm for the diagnosis of otitis media. Acad Pediatr 2012; 12:214.
  5. Rovers MM, Glasziou P, Appelman CL, et al. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet 2006; 368:1429.
  6. Venekamp RP, Sanders SL, Glasziou PP, et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2015; :CD000219.
  7. Thompson M, Vodicka TA, Blair PS, et al. Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013; 347:f7027.
  8. Teele DW, Klein JO, Rosner BA. Epidemiology of otitis media in children. Ann Otol Rhinol Laryngol Suppl 1980; 89:5.
  9. Questions & Answers: Reports of a rare, but serious and potentially fatal adverse effect with the use of over-the-counter (OTC) benzocaine gels and liquids applied to the gums or mouth www.fda.gov/Drugs/DrugSafety/ucm250029.htm (Accessed on August 03, 2012).
  10. US Food and Drug Administration. Unapproved prescription ear drop (otic) products: Not FDA evaluated for safety, effectiveness, and quality http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm453430.htm (Accessed on July 02, 2015).
  11. Sjoukes A, Venekamp RP, van de Pol AC, et al. Paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs, alone or combined, for pain relief in acute otitis media in children. Cochrane Database Syst Rev 2016; 12:CD011534.
  12. Foxlee R, Johansson AC, Wejfalk J, et al. Topical analgesia for acute otitis media. Cochrane Database Syst Rev 2011; :CD005657.
  13. Hoberman A, Paradise JL, Reynolds EA, Urkin J. Efficacy of Auralgan for treating ear pain in children with acute otitis media. Arch Pediatr Adolesc Med 1997; 151:675.
  14. Bolt P, Barnett P, Babl FE, Sharwood LN. Topical lignocaine for pain relief in acute otitis media: results of a double-blind placebo-controlled randomised trial. Arch Dis Child 2008; 93:40.
  15. Coleman C, Moore M. Decongestants and antihistamines for acute otitis media in children. Cochrane Database Syst Rev 2008; :CD001727.
  16. Chonmaitree T, Saeed K, Uchida T, et al. A randomized, placebo-controlled trial of the effect of antihistamine or corticosteroid treatment in acute otitis media. J Pediatr 2003; 143:377.
  17. Use of codeine- and dextromethorphan-containing cough remedies in children. American Academy of Pediatrics. Committee on Drugs. Pediatrics 1997; 99:918.
  18. Choosing Wisely. American Academy of Pediatrics. http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-pediatrics/ (Accessed on March 07, 2013).
  19. Sarrell EM, Mandelberg A, Cohen HA. Efficacy of naturopathic extracts in the management of ear pain associated with acute otitis media. Arch Pediatr Adolesc Med 2001; 155:796.
  20. Hoberman A, Ruohola A, Shaikh N, et al. Acute otitis media in children younger than 2 years. JAMA Pediatr 2013; 167:1171.
  21. McCormick DP, Chonmaitree T, Pittman C, et al. Nonsevere acute otitis media: a clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment. Pediatrics 2005; 115:1455.
  22. Spiro DM, Tay KY, Arnold DH, et al. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA 2006; 296:1235.
  23. Little P, Gould C, Williamson I, et al. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. BMJ 2001; 322:336.
  24. Little P, Moore M, Warner G, et al. Longer term outcomes from a randomised trial of prescribing strategies in otitis media. Br J Gen Pract 2006; 56:176.
  25. Tähtinen PA, Laine MK, Ruuskanen O, Ruohola A. Delayed versus immediate antimicrobial treatment for acute otitis media. Pediatr Infect Dis J 2012; 31:1227.
  26. Spurling GK, Del Mar CB, Dooley L, et al. Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev 2013; :CD004417.
  27. Takata GS, Chan LS, Shekelle P, et al. Evidence assessment of management of acute otitis media: I. The role of antibiotics in treatment of uncomplicated acute otitis media. Pediatrics 2001; 108:239.
  28. Glasziou PP, Del Mar CB, Sanders SL, Hayem M. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2004; :CD000219.
  29. Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr 1994; 124:355.
  30. Coker TR, Chan LS, Newberry SJ, et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: a systematic review. JAMA 2010; 304:2161.
  31. Wald ER. Acute otitis media: more trouble with the evidence. Pediatr Infect Dis J 2003; 22:103.
  32. Wald ER. To treat or not to treat. Pediatrics 2005; 115:1087.
  33. Pichichero ME, Casey JR. Diagnostic inaccuracy and subject exclusions render placebo and observational studies of acute otitis media inconclusive. Pediatr Infect Dis J 2008; 27:958.
  34. Klein JO. Is acute otitis media a treatable disease? N Engl J Med 2011; 364:168.
  35. Tähtinen PA, Laine MK, Huovinen P, et al. A placebo-controlled trial of antimicrobial treatment for acute otitis media. N Engl J Med 2011; 364:116.
  36. Hoberman A, Paradise JL, Rockette HE, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med 2011; 364:105.
  37. Kaleida PH, Casselbrant ML, Rockette HE, et al. Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial. Pediatrics 1991; 87:466.
  38. Rovers MM, Glasziou P, Appelman CL, et al. Predictors of pain and/or fever at 3 to 7 days for children with acute otitis media not treated initially with antibiotics: a meta-analysis of individual patient data. Pediatrics 2007; 119:579.
  39. Wald ER, Mason EO Jr, Bradley JS, et al. Acute otitis media caused by Streptococcus pneumoniae in children's hospitals between 1994 and 1997. Pediatr Infect Dis J 2001; 20:34.
  40. Kellner JD, Ford-Jones EL. Streptococcus pneumoniae carriage in children attending 59 Canadian child care centers. Toronto Child Care Centre Study Group. Arch Pediatr Adolesc Med 1999; 153:495.
  41. Chung A, Perera R, Brueggemann AB, et al. Effect of antibiotic prescribing on antibiotic resistance in individual children in primary care: prospective cohort study. BMJ 2007; 335:429.
  42. Wroe PC, Lee GM, Finkelstein JA, et al. Pneumococcal carriage and antibiotic resistance in young children before 13-valent conjugate vaccine. Pediatr Infect Dis J 2012; 31:249.
  43. Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance--a report from the Drug-resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatr Infect Dis J 1999; 18:1.
  44. Seikel K, Shelton S, McCracken GH Jr. Middle ear fluid concentrations of amoxicillin after large dosages in children with acute otitis media. Pediatr Infect Dis J 1997; 16:710.
  45. Jacobs MR, Bajaksouzian S, Zilles A, et al. Susceptibilities of Streptococcus pneumoniae and Haemophilus influenzae to 10 oral antimicrobial agents based on pharmacodynamic parameters: 1997 U.S. Surveillance study. Antimicrob Agents Chemother 1999; 43:1901.
  46. Tristram S, Jacobs MR, Appelbaum PC. Antimicrobial resistance in Haemophilus influenzae. Clin Microbiol Rev 2007; 20:368.
  47. Thanaviratananich S, Laopaiboon M, Vatanasapt P. Once or twice daily versus three times daily amoxicillin with or without clavulanate for the treatment of acute otitis media. Cochrane Database Syst Rev 2013; :CD004975.
  48. Dagan R. The use of pharmacokinetic/pharmacodynamic principles to predict clinical outcome in paediatric acute otitis media. Int J Antimicrob Agents 2007; 30 Suppl 2:S127.
  49. Murph JR, Dusdieker LB, Booth B, Murph WE. Is treatment of acute otitis media with once-a-day amoxicillin feasible? Results of a pilot study. Clin Pediatr (Phila) 1993; 32:528.
  50. Klein JO. Review of consensus reports on management of acute otitis media. Pediatr Infect Dis J 1999; 18:1152.
  51. Critchley IA, Jacobs MR, Brown SD, et al. Prevalence of serotype 19A Streptococcus pneumoniae among isolates from U.S. children in 2005-2006 and activity of faropenem. Antimicrob Agents Chemother 2008; 52:2639.
  52. Jacobs MR. Antimicrobial-resistant Streptococcus pneumoniae: trends and management. Expert Rev Anti Infect Ther 2008; 6:619.
  53. Steele RW, Thomas MP, Begue RE, Despinasse BP. Selection of pediatric antibiotic suspensions: Taste and cost factors. Infect Med 1999; 16:197.
  54. American Academy of Pediatrics. Tables of antibacterial drug dosages. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.881.
  55. Hendrickse WA, Kusmiesz H, Shelton S, Nelson JD. Five vs. ten days of therapy for acute otitis media. Pediatr Infect Dis J 1988; 7:14.
  56. Goldblatt EL, Dohar J, Nozza RJ, et al. Topical ofloxacin versus systemic amoxicillin/clavulanate in purulent otorrhea in children with tympanostomy tubes. Int J Pediatr Otorhinolaryngol 1998; 46:91.
  57. Suzuki K, Nishimura T, Baba S, et al. Topical ofloxacin for chronic suppurative otitis media and acute exacerbation of chronic otitis media: optimum duration of treatment. Otol Neurotol 2003; 24:447.
  58. Hoberman A, Paradise JL, Burch DJ, et al. Equivalent efficacy and reduced occurrence of diarrhea from a new formulation of amoxicillin/clavulanate potassium (Augmentin) for treatment of acute otitis media in children. Pediatr Infect Dis J 1997; 16:463.
  59. Pessey JJ, Gehanno P, Thoroddsen E, et al. Short course therapy with cefuroxime axetil for acute otitis media: results of a randomized multicenter comparison with amoxicillin/clavulanate. Pediatr Infect Dis J 1999; 18:854.
  60. Hoberman A, Paradise JL, Rockette HE, et al. Shortened Antimicrobial Treatment for Acute Otitis Media in Young Children. N Engl J Med 2016; 375:2446.
  61. Cohen R, Levy C, Chalumeau M. Shortened Antimicrobial Treatment for Acute Otitis Media. N Engl J Med 2017; 376:e24.
  62. Kozyrskyj A, Klassen TP, Moffatt M, Harvey K. Short-course antibiotics for acute otitis media. Cochrane Database Syst Rev 2010; :CD001095.
  63. Kenna MA. Acute Otitis Media - The Long and the Short of It. N Engl J Med 2016; 375:2492.
  64. Cates C. An evidence based approach to reducing antibiotic use in children with acute otitis media: controlled before and after study. BMJ 1999; 318:715.
  65. Siegel RM, Kiely M, Bien JP, et al. Treatment of otitis media with observation and a safety-net antibiotic prescription. Pediatrics 2003; 112:527.
  66. Chao JH, Kunkov S, Reyes LB, et al. Comparison of two approaches to observation therapy for acute otitis media in the emergency department. Pediatrics 2008; 121:e1352.
  67. Uitti JM, Tähtinen PA, Laine MK, Ruohola A. Close Follow-up in Children With Acute Otitis Media Initially Managed Without Antimicrobials. JAMA Pediatr 2016; 170:1107.
  68. American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004; 113:1451.
  69. Bluestone CD. Clinical course, complications and sequelae of acute otitis media. Pediatr Infect Dis J 2000; 19:S37.
  70. Bluestone CD. Epidemiology and pathogenesis of chronic suppurative otitis media: implications for prevention and treatment. Int J Pediatr Otorhinolaryngol 1998; 42:207.
  71. Bluestone CD, Klein JO. Management. In: Otitis Media in Infants and Children, 4th ed, BC Decker, Hamilton, ON 2007. p.213.
  72. Al-Shawwa BA, Wegner D. Trimethoprim-sulfamethoxazole plus topical antibiotics as therapy for acute otitis media with otorrhea caused by community-acquired methicillin-resistant Staphylococcus aureus in children. Arch Otolaryngol Head Neck Surg 2005; 131:782.
  73. Santos F, Mankarious LA, Eavey RD. Methicillin-resistant Staphylococcus aureus: pediatric otitis. Arch Otolaryngol Head Neck Surg 2000; 126:1383.
  74. Pichichero ME, Casey JR. Emergence of a multiresistant serotype 19A pneumococcal strain not included in the 7-valent conjugate vaccine as an otopathogen in children. JAMA 2007; 298:1772.
  75. Block SL, Busman TA, Paris MM, Bukofzer S. Comparison of five-day cefdinir treatment with ten-day low dose amoxicillin/clavulanate treatment for acute otitis media. Pediatr Infect Dis J 2004; 23:834.
  76. Steele RW, Thomas MP, Bégué RE. Compliance issues related to the selection of antibiotic suspensions for children. Pediatr Infect Dis J 2001; 20:1.
  77. Leibovitz E, Piglansky L, Raiz S, et al. Bacteriologic and clinical efficacy of one day vs. three day intramuscular ceftriaxone for treatment of nonresponsive acute otitis media in children. Pediatr Infect Dis J 2000; 19:1040.
  78. Arguedas A, Dagan R, Pichichero M, et al. An open-label, double tympanocentesis study of levofloxacin therapy in children with, or at high risk for, recurrent or persistent acute otitis media. Pediatr Infect Dis J 2006; 25:1102.
  79. Pletz MW, McGee L, Jorgensen J, et al. Levofloxacin-resistant invasive Streptococcus pneumoniae in the United States: evidence for clonal spread and the impact of conjugate pneumococcal vaccine. Antimicrob Agents Chemother 2004; 48:3491.
  80. Doern GV, Pfaller MA, Kugler K, et al. Prevalence of antimicrobial resistance among respiratory tract isolates of Streptococcus pneumoniae in North America: 1997 results from the SENTRY antimicrobial surveillance program. Clin Infect Dis 1998; 27:764.
  81. Pichichero ME. Otitis media. Pediatr Clin North Am 2013; 60:391.
  82. Rosenfeld RM, Schwartz SR, Pynnonen MA, et al. Clinical practice guideline: Tympanostomy tubes in children. Otolaryngol Head Neck Surg 2013; 149:S1.
  83. Morgagni F, Autore A, Landolfi A, et al. Predictors of ear barotrauma in aircrews exposed to simulated high altitude. Aviat Space Environ Med 2012; 83:594.
  84. Otalgia in infants traveling in airplanes. N Engl J Med 1983; 308:781.
  85. Ishiyama A. Why does air travel cause earache? West J Med 1999; 171:106.
  86. Bettes TN, McKenas DK. Medical advice for commercial air travelers. Am Fam Physician 1999; 60:801.
  87. Stangerup SE, Tjernström O, Harcourt J, et al. Barotitis in children after aviation; prevalence and treatment with Otovent. J Laryngol Otol 1996; 110:625.
  88. Buchanan BJ, Hoagland J, Fischer PR. Pseudoephedrine and air travel-associated ear pain in children. Arch Pediatr Adolesc Med 1999; 153:466.