Paeds
Acute Otitis Media
Library·Paediatrics·Acute otitis media
Don't miss
- Mastoiditis - post-auricular swelling, erythema, tenderness, protruding ear - same-day
- Facial palsy in AOM - urgent ENT
- Persistent CSOM in tamariki Maori or Pacific - high baseline rate, ENT referral, language delay risk
- Recurrent AOM disrupting language and learning - audiology + ENT pathway
First-line
- Diagnosis
- Rapid onset + middle ear effusion + middle ear inflammation. Red TM alone is not enough
- Watchful waiting
- Mild-moderate AOM in >2-year-old - 80% resolve in 72 hours. Adequate analgesia
- Antibiotics if
- Under 2, bilateral, perforation/discharge, severe, comorbidity, or failure at 48-72 hours
- First choice
- Amoxicillin 40 mg/kg/day TDS × 5 days. Topical ciprofloxacin (NOT aminoglycoside) if perforated
Refer when
- Mastoiditis or facial nerve palsy - same-day
- CSOM (persistent discharge through perforation) - ENT
- Recurrent AOM (≥3 in 6 months or ≥4 in a year)
- Persistent hearing concerns or speech delay
Tell whanau
- Most ear infections clear up on their own with paracetamol and time
- Antibiotics often are not needed - we will say if they are
- Come back if pain >3 days, fever returns, swelling behind the ear, or your tamaiti is unwell
- Hearing checks matter - tell us if you notice changes
Acute otitis media (AOM) is one of the most common bacterial infections of childhood and the most frequent reason children receive antibiotics in primary care. New Zealand has among the highest rates of childhood ear disease in the developed world, with marked disparities affecting Maori and Pacific children. Chronic suppurative otitis media (CSOM) affects approximately 4% of Maori and Pacific children, compared with under 1% of NZ European children.1 Hearing loss from chronic ear disease is a significant driver of language delay and educational disadvantage, and the consequences compound over time.
❍ Diagnosis
AOM presents with rapid onset of ear pain, often accompanied by fever and irritability, frequently following a few days of viral upper respiratory illness. In infants and pre-verbal children, non-specific signs predominate: fever, irritability, pulling at the ear, disturbed sleep, poor feeding, and vomiting.
Diagnosis requires all three of:2
- Rapid onset of symptoms
- Evidence of middle ear effusion on otoscopy: bulging tympanic membrane, reduced mobility on pneumatic otoscopy, or visible air-fluid level
- Signs of middle ear inflammation: TM erythema, distinct otalgia, or perforation with discharge
A red tympanic membrane alone, without bulging, is not sufficient for an AOM diagnosis. It may simply reflect a crying child. AOM with perforation (visible discharge through the TM) represents a more severe form and antibiotics are indicated regardless of age.
AOM is a clinical diagnosis. Routine investigations are not required unless complications are suspected. Tympanometry detects middle ear effusion but does not distinguish AOM from OME and is not available in most NZ GP settings. Audiological assessment is indicated if hearing loss is suspected or if there are developmental concerns in a child with recurrent episodes.
❍ Watchful waiting and analgesia
For children aged 2 years and over with mild-to-moderate AOM and no complicating factors, watchful waiting with adequate analgesia is the appropriate first-line approach.3 The rationale: 80% of uncomplicated episodes resolve spontaneously within 72 hours, and antibiotics reduce pain duration by less than one day while contributing to resistance and adverse effects.
Analgesia is the priority, regardless of whether antibiotics are prescribed. Paracetamol 15 mg/kg 4-6 hourly and/or ibuprofen 5-10 mg/kg 6-8 hourly (in children over 3 months) provides meaningful pain relief. Ear pain in AOM can be severe - adequate dosing matters.
A delayed prescription strategy is an effective middle ground: provide a prescription with instruction to fill it only if symptoms worsen or fail to improve after 48 hours. This approach reduces antibiotic use without increasing complications or parental anxiety.
❍ When antibiotics are indicated
Prescribe antibiotics immediately for:3
- Age under 2 years (higher complication risk, less likely to resolve spontaneously)
- Bilateral AOM (higher rate of bacterial aetiology and complications)
- AOM with perforation and discharge
- Severe symptoms: high fever, severe pain, or very unwell child
- Significant comorbidities: immunodeficiency, craniofacial abnormality, cochlear implant
- Failure to improve after 48-72 hours of watchful waiting
First-line antibiotic: amoxicillin 40 mg/kg/day in 3 divided doses (max 1.5 g/day) for 5 days. Where amoxicillin-resistant organisms are suspected - prior antibiotic exposure, or failure to respond after 48-72 hours - switch to amoxicillin-clavulanate (Augmentin).
❍ CSOM and referral
CSOM is persistent discharge through a perforated tympanic membrane. For Maori and Pacific children, the prevalence is approximately 4%, reflecting a combination of socioeconomic factors, household crowding, and possibly genetic predisposition to Eustachian tube dysfunction. Early recognition and appropriate management of AOM is part of preventing CSOM, but the referral threshold should be low in high-risk groups.
CSOM management in primary care: topical ciprofloxacin ear drops are first-line. Aminoglycosides (gentamicin, neomycin) are ototoxic when the eardrum is perforated and should not be used. Keep the ear dry - cotton ball plug when bathing, no swimming while discharging. ENT referral for all persistent CSOM