Otitis media (middle ear infection)

Otitis media is inflammation or infection of the middle ear — the air-filled space behind the eardrum that contains the small hearing bones. Acute otitis media (AOM) is a rapid-onset infection, most common in young children, often following a cold. Otitis media with effusion (OME) is fluid in the middle ear without acute infection symptoms.

Children are more susceptible because their eustachian tubes are shorter and more horizontal. Most uncomplicated acute infections improve with pain management; antibiotics are used selectively based on age, severity, and laterality. Recurrent infections or persistent fluid may require further evaluation and sometimes ear tubes.

Symptoms of acute otitis media may include:

• Ear pain (tugging or pulling at the ear in infants and toddlers)
• Fussiness, irritability, and trouble sleeping
• Hearing difficulty or a feeling of fullness
• Fever
• Fluid drainage from the ear (if the eardrum ruptures)
• Balance problems or clumsiness
• Headache and loss of appetite

OME causes hearing muffling or fullness without acute pain or fever. Chronic suppurative otitis media involves persistent drainage through a perforated eardrum.

Acute otitis media usually follows eustachian tube dysfunction from a viral upper respiratory infection, allowing bacteria (or sometimes viruses) to proliferate in the middle-ear space. Common bacteria include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Risk is increased by group childcare exposure, bottle-feeding while lying down, smoke exposure, and incomplete vaccination. OME results from persistent fluid after infection or from ongoing eustachian tube dysfunction related to allergies or anatomy.

Risk factors include:

• Young age (peak 6–18 months)
• Group daycare attendance
• Family history of frequent ear infections
• Smoke exposure
• Bottle feeding (especially while supine) rather than breastfeeding
• Pacifier use in some studies
• Craniofacial abnormalities (cleft palate) and Down syndrome
• Seasonal upper respiratory infection peaks
• Incomplete pneumococcal and influenza vaccination

Most children recover fully. Possible complications include:

• Hearing loss (usually temporary from fluid; rarely permanent)
• Speech or developmental delay with prolonged bilateral hearing impairment
• Tympanic membrane perforation
• Chronic middle-ear effusion or chronic suppurative otitis media
• Mastoiditis, meningitis, or brain abscess (rare in the antibiotic era)
• Cholesteatoma with chronic disease

Helpful measures:

• Breastfeed when possible for at least several months
• Avoid bottle-feeding while the infant is lying flat
• Do not expose children to tobacco smoke
• Keep up to date with pneumococcal, influenza, and other recommended vaccines
• Practice good hand hygiene to reduce colds
• Limit pacifier use after 6–12 months if infections are frequent
• Manage allergies when present

Diagnosis of AOM requires acute onset of symptoms, signs of middle-ear effusion, and signs of middle-ear inflammation (bulging eardrum, limited mobility, or otorrhea). Pneumatic otoscopy is the key examination skill. Tympanometry can confirm effusion. Routine cultures are not obtained unless the ear is draining or infection is severe/recurrent. Hearing testing is considered for persistent OME.

See a clinician for ear pain, fever, ear drainage, or hearing concerns, especially in young children. Seek prompt care for severe pain, high fever, swelling behind the ear, stiffness of the neck, or symptoms in an infant younger than 6 months.

Pain management is essential for all children — acetaminophen or ibuprofen at appropriate doses; warm or cold compresses.

Antibiotics are recommended for:

• All infants under 6 months with AOM
• Children 6 months and older with severe signs (moderate–severe pain or fever ≥39°C)
• Bilateral AOM in children under 24 months
• Observation with close follow-up is an option for selected non-severe unilateral cases in children 6–23 months and for non-severe cases in older children

First-line antibiotic is typically high-dose amoxicillin when appropriate; alternatives are used for allergy or recent antibiotic exposure. Duration is often 5–10 days depending on age and severity.

Recurrent AOM or persistent OME may warrant referral for tympanostomy tubes and, when indicated, adenoidectomy. Decongestants and antihistamines are not routinely recommended for AOM.

At home:

• Give pain medicine regularly for the first day or two as needed
• Encourage fluids and rest
• Keep follow-up appointments, especially if observation without immediate antibiotics was chosen
• Complete the antibiotic course if prescribed
• Protect the ear from water if the eardrum is perforated or tubes are present, as advised
• Return for care if symptoms worsen or do not improve within 48–72 hours

Bring:

• Symptom timeline, including fever and pain severity
• Number of prior ear infections and any previous antibiotic use
• Vaccination history
• Allergy history (especially to antibiotics)
• Questions about observation vs antibiotics and when tubes might be considered