Guideline sources The following summarized guidelines for the evaluation and management of acute otitis media (AOM) are prepared by our editorial team based on guidelines from the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2022), the Italian Society of Pediatrics (ISP 2019), the Danish Society of Otorhinolaryngology, Head and Neck Surgery (DSOHH/DHMA 2016), and the American Academy of Pediatrics (AAP/AAFP 2013). 1 2 3 4 5 6 7 7 8 Definition AOM is defined as an infection of the middle ear space. 6 Epidemiology AOM is mostly caused by bacteria (S. pneumoniae, H. influenzae, Moraxella catarrhalis) followed by viruses. 7 Disease course https://web.pathway.md/diseases/recrzrleSMkm8ym6n 1/6 6/23/23, 2:02 AM Acute otitis media Pathway The inflammatory disease due to middle ear space infection with particular involvement of the tympanic membrane results in AOM, which presents with clinical presentations of earache, otorrhea, headache, fever, general malaise, and hearing impairment. AOM is a self-limiting condition. 8 Prognosis and risk of recurrence AOM is not associated with an increase in mortality. 7 Guidelines 1. Screening and diagnosis Diagnostic criteria: As per ISP 2019 guidelines, view the sole presence of otorrhea, not secondary to external otitis, associated with spontaneous perforation of the tympanic membrane as a certain objective sign of AOM. A As per AAFP 2013 guidelines, diagnose AOM in children who present with moderate-to-severe bulging of the tympanic membrane, or new onset of otorrhea not due to acute otitis externa. B 2. Diagnostic investigations Clinical assessment: As per AAO-HNSF 2022 guidelines, assess whether the pediatric patient with recurrent otitis media with effusion of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors. B As per ISP 2019 guidelines, assess for the presence and degree of signs and symptoms (including fever, pain, irritability, otorrhea, tympanic membrane hyperemia, bulging, and mobility) in all patients. B Tympanic membrane assessment: As per ISP 2019 guidelines, examine the tympanic membrane for hyperemia, bulging, and mobility in all patients. B Show 4 more As per DHMA 2016 guidelines, examine the mobility of the tympanic membrane by pneumatic otoscopy or tympanometry when diagnosing AOM. B 3. Medical management Analgesics: As per ISP 2019 guidelines: https://web.pathway.md/diseases/recrzrleSMkm8ym6n 2/6 6/23/23, 2:02 AM Acute otitis media Pathway Prioritize assessment and treatment of otalgia in patients with AOM. Administer adequate doses of ibuprofen or acetaminophen. A Do not use topical analgesic drops or analgesic preparations based on natural extracts due to the lack of available high-quality evidence. D As per AAFP 2013 guidelines, assess for pain as part of the management of AOM, and offer analgesic treatment if present. B Systemic antibiotics, indications, young children: As per ISP 2019 guidelines, initiate antibiotic therapy in < 6 months old patients with AOM and in all pediatric patients with otorrhea, intracranial complications, and/or a history of recurrence. Show 2 more As per DHMA/DSOHH 2016 guidelines, offer close observation without prescribing antibiotics in preschool-aged patients with symptoms of AOM without middle ear effusion. E As per AAP/AAFP 2013 guidelines, initiate antibiotic therapy in 6 months old patients with AOM (bilateral or unilateral) with severe signs or symptoms, including: moderate or severe otalgia duration of otalgia 48 hours temperature > 39 C. B Show 2 more Systemic antibiotics, indications, older children: As per ISP 2019 guidelines, consider offering a watchful waiting approach on a case-by-case basis in > 2 years old patients with mild or severe unilateral AOM or mild bilateral AOM, if follow- up is possible within 48-72 hours. B As per AAP/AAFP 2013 guidelines: Initiate antibiotic therapy, or offer observation with close follow-up based on joint decision- making with the parent/caregiver, in 24 months old patients with AOM without severe signs or symptoms. B Ensure follow-up when observation is used as an initial strategy with the initiation of antibiotic therapy when the patient worsens or fails to improve within 48-72 hours of the onset of symptoms. B Systemic antibiotics, regimens: As per ISP 2019 guidelines, administer amoxicillin at a dose of 80-90 mg/kg/day (divided into 3 doses) in pediatric patients with uncomplicated AOM with mild signs and symptoms in the absence of risk factors for bacterial resistance and with no history of recurrence. A Show 7 more As per AAP/AAFP 2013 guidelines: Adminsiter amoxicillin as first-line therapy in patients with uncomplicated AOM in the absence of penicillin allergy, recent treatment with amoxicillin, and purulent conjunctivitis. B Administer an antibiotic with additional -lactamase coverage in patients meeting any of the following criteria: https://web.pathway.md/diseases/recrzrleSMkm8ym6n 3/6 6/23/23, 2:02 AM Acute otitis media Pathway receipt of amoxicillin in the last 30 days presence of concurrent purulent conjunctivitis history of recurrent AOM unresponsive to amoxicillin. B Topical antibiotics: do not use topical antibiotics (with or without corticosteroids) except in patients with tympanostomy tubes. D Decongestants: avoid using systemic or topical decongestants in patients with AOM. D Corticosteroids: avoid using systemic or topical corticosteroids in patients with AOM. D 4. Nonpharmacologic interventions Nasal irrigation: consider performing nasal lavage to remove nasal secretions as a complementary therapeutic measure. C 5. Therapeutic procedures Cerumen removal: consider removing the cerumen from the external auditory canal, performed by an appropriately trained pediatrician or by an otolaryngologist, with various operational and organizational methods depending on the care setting, the level of the practitioner's expertise, and the instruments available. C 6. Surgical interventions Tympanostomy: As per AAO-HNSF 2022 guidelines, offer bilateral tympanostomy tube insertion in pediatric patients with recurrent AOM with unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy. B Show 2 more As per DHMA 2016 guidelines, consider offering ventilating tube insertion in preschool-aged patients with recurrent AOM, with or without middle ear effusion between AOM episodes. C As per AAFP 2013 guidelines, consider offering tympanostomy tubes for children with recurrent AOM (3 episodes in 6 months, or 4 episodes in 1 year with 1 episode occurring in the preceding 6 months). C Adenoidectomy: As per AAO-HNSF 2022 guidelines, consider performing adenoidectomy as an adjunct to tympanostomy tube insertion in pediatric patients with symptoms directly related to the adenoids (adenoid infection or nasal obstruction) or in 4 years old patients to potentially reduce future incidence of recurrent otitis media or the need for repeat tube insertion. C As per DHMA 2016 guidelines, consider offering adjuvant adenoidectomy after careful consideration in preschool-aged patients scheduled for first time ventilation tube insertion for https://web.pathway.md/diseases/recrzrleSMkm8ym6n 4/6 6/23/23, 2:02 AM Acute otitis media Pathway recurrent AOM. C 7. Patient education Assessment of treatment response: reassess patients in whom symptoms worsen or fail to respond to initial antibiotic treatment within 48-72 hours, and determine whether a change in therapy is needed. B 8. Preventative measures Routine immunizations: Provide influenza immunization on an annual basis to all children, according to established national schedules. B Provide pneumococcal immunization to all children, according to established national schedules. B Breastfeeding: encourage exclusive breastfeeding for at least 6 months to prevent AOM in infants. B Avoidance of smoke exposure: encourage avoidance of tobacco smoke exposure to prevent AOM. B Prophylactic antibiotics: avoid prescribing prophylactic antibiotics to reduce the frequency of episodes of AOM in children with recurrent AOM. D References 1. Richard M Rosenfeld, David E Tunkel, Seth R Schwartz et al. Clinical Practice Guideline: Tympanostomy Tubes in Children Update). Otolaryngol Head Neck Surg. 2022 Feb;166 1_suppl):S1 S55. Open 2. Paola Marchisio, Luisa Galli, Barbara Bortone et al. Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics: Treatment. Pediatr Infect Dis J. 2019 Dec;38 12S Suppl):S10 S21. Open 3. C H Heidemann, J Lous, J Berg et al. Danish guidelines on management of otitis media in preschool children. Int J Pediatr Otorhinolaryngol. 2016 Aug;87 154 63. Open 4. Lieberthal AS, Carroll AE, Chonmaitree T et al. The diagnosis and management of acute otitis media. Pediatrics. 2013 Mar;131 3):e964 99. Open 5. Elena Chiappini, Martina Ciarci , Barbara Bortone et al. Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics: Diagnosis. Pediatr Infect Dis J. 2019 Dec;38 12S Suppl):S3 S9. Open 6. Amina Danishyar, John V. Ashurst. Acute Otitis Media. StatPearls Internet]. Treasure Island FL StatPearls Publishing; 2020 Jan. 2020 Nov 22. Open 7. Graham Worrall. Acute otitis media. 2007 Dec;53 12 2147 8.2007 Dec;53 12 2147 8. Open https://web.pathway.md/diseases/recrzrleSMkm8ym6n 5/6 6/23/23, 2:02 AM Acute otitis media Pathway 8. Jan Peter Thomas, Reinhard Berner, Thomas Zahnert et al. Acute otitis media a structured approach. 2014 Feb 28;111 9 151 9; quiz 160.2014 Feb 28;111 9 151 9; quiz 160. Open 9. American Association of Family Physicians. Choosing Wisely AAFP recommendations. Choosing Wisely. 2013. Open 10. Roger Zoorob, Mohamad A Sidani, Richard D Fremont et al. Antibiotic use in acute upper respiratory tract infections. Am Fam Physician. 2012 Nov 1;86 9 817 22. Open https://web.pathway.md/diseases/recrzrleSMkm8ym6n 6/6