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South Australian Paediatric Clinical Practice Guidelines 

Acute Otitis Media in Children 
    Department for Health and Wellbeing, Government of South Australia. All rights reserved. 

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Note:
This guideline provides advice of a general nature.  This statewide guideline has been prepared to promote and 
facilitate standardisation and consistency of practice, using a multidisciplinary approach.  The guideline is based on 
a review of published evidence and expert opinion.  
Information in this statewide guideline is current at the time of publication.  
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and 
does not sponsor, approve or endorse materials on such links. 
Health practitioners in the South Australian public health sector are expected to review specific details of each 
patient and professionally assess the applicability of the relevant guideline to that clinical situation. 
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document 
in the patient s medical record, the decision made, by whom, and detailed reasons for the departure from the 
guideline. 
This statewide guideline does not address all the elements of clinical practice and assumes that the individual 
clinicians are responsible for discussing care with consumers in an environment that is culturally appropriate and 
which enables respectful confidential discussion. This includes: 

  The use of interpreter services where necessary, 
  Advising consumers of their choice and ensuring informed consent is obtained, 
  Providing care within scope of practice, meeting all legislative requirements and maintaining 

standards of professional conduct, and  
  Documenting all care in accordance with mandatory and local requirements 

 
Explanation of the aboriginal artwork: 
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. The 
horse shoe shape design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant woman. 
The smaller horse shoe shape in this instance represents the unborn child. The artwork shown before the specific statements within the document symbolises a 
footprint and demonstrates the need to move forward together in unison. 

     

 

 

 

 

 

 
 
 
 
 
 
The term  Aboriginal  is used to refer to people who identify as Aboriginal, Torres Strait Islanders, or both Aboriginal and Torres Strait 
Islander.  This is done because the people indigenous to South Australia are Aboriginal and we respect that many Aboriginal people prefer the 
term  Aboriginal .  We also acknowledge and respect that many Aboriginal South Australians prefer to be known by their specific language 
group(s). 

 Cultural safety enhances clinical safety.  

To secure the best health outcomes, clinicians must provide a culturally safe health care 
experience for Aboriginal children, young people and their families. Aboriginal children 
are born into strong kinship structures where roles and responsibilities are integral and 
woven into the social fabric of Aboriginal societies. 

Australian Aboriginal culture is the oldest living culture in the world, yet Aboriginal 
people currently experience the poorest health outcomes when compared to non-
Aboriginal Australians. 
 
It remains a national disgrace that Australia has one of the highest youth suicide rates in 
the world.  The over representation of Aboriginal children and young people in out of 
home care and juvenile detention and justice system is intolerable. 
 
The cumulative effects of forced removal of Aboriginal children, poverty, exposure to 
violence, historical and transgenerational trauma, the ongoing effects of past and present 
systemic racism, culturally unsafe and discriminatory health services are all major 
contributors to the disparities in Aboriginal health outcomes. 
 
Clinicians can secure positive long term health and wellbeing outcomes by making well 
informed clinical decisions based on cultural considerations. 

 



Acute Otitis Media in Children 
 

 

 
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Purpose and Scope of PCPG 
To provide a clinical practice guideline for the management of acute otitis media in children. 

Exclusions 
&gt; This guideline does not deal specifically with the management of acute otitis media or its 

complications in Aboriginal and Torres Strait Islander Populations. For clinical care 
guidelines on the  Management of Otitis Media in Aboriginal and Torres Strait Islander 
Populations  follow link to the Department of Health and Ageing website 

http://www.health.gov.au/internet/main/publishing.nsf/Content/indigenous-otitismedia-
clinical-care-guidelines. 

&gt; This guideline will not discuss the management of complications of acute otitis media; 
however it will refer to how to diagnose them, as well as appropriate referral and disposition 
of such patients. 

Flowchart: Suggested antibiotic usage for acute otitis media 
 
Diagram 1: Commencing antibiotics 

  
 

  






Acute Otitis Media in Children 
 

 

 
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Table of Contents 

 
Purpose and Scope of PCPG ....................................................................................................... 2 

Exclusions ..................................................................................................................................... 2 

Flowchart: Suggested antibiotic usage for acute otitis media ...................................................... 2 

Table of Contents ......................................................................................................................... 3 

Summary of Practice Recommendations ..................................................................................... 3 

Abbreviations ................................................................................................................................ 4 

Definitions ..................................................................................................................................... 4 

Acute otitis media in children ........................................................................................................ 4 

Management ................................................................................................................................. 5 

Complications ............................................................................................................................... 6 

Acute mastoiditis ........................................................................................................................... 7 

Bullous myringitis .......................................................................................................................... 7 

Infected tympanostomy tubes (grommets) ................................................................................... 8 

References .................................................................................................................................... 9 

 

 

Summary of Practice Recommendations  
&gt; Acute otitis media (AOM), a common condition in children, is a closed space inflammatory 

process in the middle ear. It is more frequent in the first 2 years of life, due to the immaturity 
of immunologic defenses and to the Eustachian tube s function and structure. 

&gt; Diagnosis is based on the presence of a triad of clinical signs. 

&gt; Management includes analgesia as well as possible antibiotic use. 

&gt; Age is important in determining whether a child can have delayed antibiotic management. 

&gt; First line antibiotic therapy is Amoxicillin. Poor response to amoxicillin may occur due to 
increasing resistance of causative bacteria. Amoxicillin with clavulanic acid (Augmentin 
Duo ) provides better coverage of Haemophilus influenzae and Moraxella catarrhalis and 
additionally, a three times daily (tds) dosing instead of the standard twice daily (bd) dosing 
increases antibiotic activity, which is required in children. 

  



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Abbreviations 
AOM Acute otitis media 
OME Otitis media with effusion 
URTI Upper respiratory tract infection 
bd Twice daily 
ENT Ear, nose and throat 
hrs Hours 
IV Intravenous 
kg Kilogram(s) 
mg Milligrams 
mL Millilitre(s) 
mo Months 
tds Three times a day 

 

Definitions 

Acute otitis 
media 

Inflammation of the middle ear in which there is fluid in the middle ear 
accompanied by signs or symptoms of ear infection: a bulging eardrum 
usually accompanied by pain; or a perforated eardrum, often with drainage of 
purulent material (pus) 

Otitis media 
with effusion 

A collection of non-infected fluid in the middle ear space. Also known as 
serous otitis media and glue ear. 

Bullous 
myringitis 

An infection of the tympanic membrane characterised by the presence of fluid 
filled blisters and severe pain.  

 
Acute otitis media in children 
Causes 
&gt; Viral (25%) 

&gt; Streptococcus pneumoniae (35%) 

&gt; Non-typable strains of Haemophilus influenzae (25%) 

&gt; Moraxella catarrhalis (15%) 

Clinical signs and symptoms 
&gt; AOM diagnosis requires the following triad of symptoms: 

o Rapid onset of symptoms e.g. earache, ear tugging, irritability 
o Middle ear effusion as evidenced by a bulging immobile tympanic membrane or fluid 

behind the tympanic membrane. Pneumatic otoscopy if available is recommended.  

o Acute inflammation, as evidenced by erythema of the tympanic membrane 
The presence of a bulging, immobile red ear drum has a positive predictive value of 83-99%. 

Assessment often finds the child presenting with other viral URTI signs. Thus, a diagnosis 
of AOM can only be made after actively looking for signs of this disease.  



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Otitis Media 

  

Image 1 &amp; 2: Bulging tympanic membranes with thick mucopurulent effusions  

Management 
&gt;  There is no evidence that antihistamines, decongestants, or corticosteroids have any 

place in AOM management. 

Analgesia: 
&gt;  Pain relief is essential for AOM. The following analgesics can be utilized: 

o First line: Paracetamol 15mg/kg/dose 
o If unsuccessful,consider ibuprofen 10mg/kg/dose 

&gt; NICE14 guidelines and RCH13 for AOM have more information on analgesia 

&gt; If pain not relieved, consider adding topical anaesthetic and consider whether this reflects a 
complication such as otitis externa or mastoiditis. 

Commencing Antibiotics (See Diagram 1):  
Start immediately 
&gt; All symptomatic children aged &lt;6 months 

&gt; Symptomatic high risk groups e.g. aboriginal population, immune suppressed 

&gt; Symptoms such as fever or vomiting or child is unwell, whilst looking for other causes of 
illness 

Well children 6-24 months 
&gt; Give pain relief and observe for 24 hours from time of symptom onset.  Watch and Wait  for 

24 hours before starting antibiotics. 

Well children aged &gt;24 months 
&gt; Give pain relief and observe for 48 hours from time of symptom onset.  Watch and Wait  for 

48 hours before starting antibiotics. 

It is recommended that, when compared with an immediate antibiotic prescribing strategy, a 
watchful waiting approach (delayed strategy) for acute otitis media reduces consumption of 
antibiotics, the intention being to consult a doctor for future episodes and the likelihood of 
adverse effects (mainly diarrhoea). It does not appear to increase the long term risks of 
mastoiditis, recurrent earache, or hearing problems. The cost however is a delay in recovery of 
symptoms by an average of one day, increased analgesic requirements and a small reduction in 
parental satisfaction with treatment. (NHS evidence. Clinical knowledge summaries-otitis media- 
acute-evidence). 

The practice of providing a prescription for delayed dispensing of antibiotics following parent 
observation is not recommended. 

  



Acute Otitis Media in Children 
 

 

 
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Oral antibiotic choices: 
First line therapy: 

&gt; Amoxicillin 15mg/kg/dose (up to 500mg) 8 hourly OR (for patients suspected to be 
nonadherent) 30mg/kg/dose (up to 1g) 12 hourly orally for 5 days. For suspension formulation, 
always round up the dose to the nearest mL increment. 

Penicillin hypersensitivity (excluding immediate hypersensitivity): 
&gt; cefuroxime (child 3 months to 2 years: 10 mg/kg up to 125 mg; 2 years or older: 15 mg/kg 

up to 500 mg) orally, 12-hourly for 5 days, round up dose to the nearest mL increment. 

Penicillin immediate hypersensitivity (anaphylaxis, airway compromise) 
&gt; trimethoprim + sulfamethoxazole (child 1 month or older) 4+20 mg/kg up to 160+800 mg 

orally, 12-hourly for 5 days. 

&gt; Azithromycin 10 mg/kg up to 500 mg orally, daily for 5 days 

Note Macrolide antibiotics have a higher rate of treatment failure, particularly for azithromycin, 
and are more expensive 

Clinicians are advised to refer to the ASCIA website for more information about immediate 
hypersensitivity reactions and management: 

https://allergy.org.au/hp/anaphylaxis/ 

Poor response to therapy: 
&gt; Patients who have an inadequate response to amoxicillin therapy within 48 to 72 hours may 

have infection caused by a beta-lactamase producing strain of H. influenzae or M. 
catarrhalis; adding clavulanate provides increased activity against these pathogens.   

&gt; Amoxicillin+clavulanate 22.5mg/kg (Max 875mg per dose), 12 hourly for 5 days.  

Note Warn the parent that there is a high incidence of concomitant diarrhoea, which is not an 
allergy. 

&gt; If the patient cannot tolerate oral antibiotics (persistent vomiting) consider referral to local 
admitting paediatric service for IV antibiotics. 

Ongoing management 

&gt; The criteria for referral to an ENT specialist (as an outpatient) depends on the age of the child 
and the severity of each acute otitis media episode (e.g. more than 6 episodes in a 12 month 
period). 

Complications 
Tympanic membrane rupture 
&gt;    Due to the pressure in the middle ear creating ischaemia of the bulging tympanic membrane 

which subsequently perforates. 

&gt;    Clinically the child has a sudden loss of otalgia, but now has bloody discharge from the ear. 

&gt;  Treatment is the same as for standard AOM with the addition of toileting the discharge with 
rolled tissue spears  6 to 8 hourly prior to the instillation of topical drops where used. 

&gt; Should the discharge not resolve within 7 days, an ENT surgeon s opinion should be sought. 

 

 

 

Image 3: Tympanic membrane perforation with tympanoscleros.   




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Acute mastoiditis 
&gt; A serious, albeit rare complication of acute otitis media. 

&gt; Patients present with otalgia, periauricular swelling and erythema, particularly post auricular 
which causes the pinna of the ear to be pushed forward. 

&gt; The infection spreads to cause purulent destruction of the mastoid bone. 

&gt; All patients presenting with this need an urgent ENT consult for advice on imaging and further 
management. 

 

 

 

 
 

 

Image 4 &amp; 5: Acute mastoiditis shown on CT and clinically 

 
Chronic otitis media with effusion 
&gt; Also known as serous otitis media or  glue ear . Self-resolving OME is frequent following 

upper respiratory tract infections and following resolution of acute otitis media.  

&gt; Persistence of the effusion for more than 3 months indicates the condition has become 
chronic. 

&gt; The causes are multifactorial, and may include infection, persistent use of a baby pacifier and 
parental smoking.  

&gt; Referral to an ENT surgeon is recommended if the 
following are present: 

o effusion lasting less than 3 months in the setting of 
speech delay or educational handicap.  

o effusion lasting more than 3 months and audiometry 
showing bilateral hearing loss. 

o structural damage to the tympanic membrane 
(significant retraction, cholesteatoma. 

 

Image 6: Air fluid levels behind 
drum  in serous otitis media 



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Bullous myringitis 
Cause 

&gt; Believed to be primarily viral, however Mycoplasma 
has been identified in some cases. 

Physical examination 

&gt; Auriscope examination reveals bulla(e) on the 
tympanic membrane that is(are) filled with serous  
or serosanguineous fluid. The ear canal may be 
affected as well. 

&gt; Risk of spontaneous rupture. 
Image 7: Bullous myringitis 

Treatment 

&gt; Analgesics 

&gt; Azithromycin 10 mg/kg up to 500 mg orally, daily for 5 days.  

Infected tympanostomy tubes (grommets) 
&gt; Children will have a history of tympanostomy tube insertion (grommets) and a discharging ear 

(otorrhoea). 

 

 
Image 8: Before tube insertion      Image 9: After tube insertion 

Cause 
The most common associated pathogens are Streptococcus pneumoniae and Haemophilus 
influenzae. 

In cases where the discharge is smelly or green, Pseudomonas infection is more likely. 

Treatment 
First line therapy is the use of non-ototoxic topical drops, e.g.ciprofloxacin drops 0.3% 5 drops 
instilled 12 hourly until the middle ear has been free of discharge for at least 3 days. 

Aminoglycoside drops have previously been used for discharging grommets and CSOM(chronic 
suppurative otitis media) however due to concerns about their safety, in particular the risk of 
ototoxicity and the availability of non-ototoxic quinolone drops, the latter are now preferred. 

If potentially ototoxic drops are prescribed informed consent is recommended. 

In the absence of significant systemic illness, oral antibiotics are not required. 

If discharge fails to settle, consider a swab and further therapy directed by results.  



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References 
1. Acute Otitis Media (revised 2018 Jul) In: eTG complete [Internet]. Melbourne: 

Therapeutic Guidelines Limited; Jul 2018 edition. Url: 
ttps://tgldcdp.tg.org.au/etgcomplete 

2. Kmietowicz, Z. Most cases of otitis media should not be treated with antibiotics, says 
NICE. BMJ 2017;358:j4398 doi: 10.1136/bmj.j4398 (Published 2017 September 22) 

3. NICE. Otitis media (acute): antimicrobial prescribing. 2017. 
www.nice.org.uk/guidance/ indevelopment/gid-apg10001. 

4. DE Tunkel M. Rosenfeld, Xavier D. Sevilla, Richard H. Schwartz, Pauline A. Thomas 
and David Alejandro Hoberman, Mary Anne Jackson, Mark D. Joffe, Donald T. Miller, 
Richard Allan S. Lieberthal, Aaron E. Carroll, Tasnee Chonmaitree, Theodore G. 
Ganiats, Clinical practice guidelines: The diagnosis and management of Acute otitis 
media; from the American academy of Paediatrics. 
www.pediatrics.org/cgi/doi/10.1542/peds.2012-3488 . 2013;131;e964Pediatrics   

5. Clinical practice guideline: Otitis Media with effusion (update). Otolaryngology  Head 
and Neck Surgery 2016, Vol. 154(1S) S1 S41 1 American Academy of 
Otolaryngology Head and Neck Surgery Foundation 2016 

6. E Rettig, D Tunkel. Contemporary concepts in management of acute otitis media in 
children. Otolaryngol Clin N Am 47 (2014) 651 6727.  

7. Steele DW, Adam GP, Di M, et al. Effectiveness of Tympanostomy Tubes for Otitis 
Media: A Meta-analysis. Pediatrics. 2017;139(6):e20170125 

8. Venekamp RP, Javed F, vanDongen TMA, Waddell A, Schilder AGM. Interventions 
for children with ear discharge occurring atleast two weeks following grommet 
(ventilation tube) insertion. CochraneDatabaseof SystematicReviews 2016, Issue 11. 
Art.No.: CD011684. DOI: 10.1002/14651858.CD011684.pub2.  

9. Venekamp RP, Burton MJ, van Dongen TMA, van der Heijden GJ, vanZon A, 
Schilder AGM. Antibiotics for otitis media with effusion in children. 
CochraneDatabaseof SystematicReviews 2016, Issue 6. Art. No.: CD009163. DOI: 
10.1002/14651858.CD009163.pub3. 

10.  Jeremy Chee a,*, Khang Wen Pang a, Jui May Yong b, Roger Chun-Man Ho c, 
Raymond Ng. Topical versus oral antibiotics, with or without corticosteroids, in the 
treatment of tympanostomy tube otorrhea. J. Chee et al./International Journal of 
Pediatric Otorhinolaryngology 86 (2016) 183-188. 

11. Ranakusuma RW, Pitoyo Y, SafitriED, Thorning S,Beller EM, SastroasmoroS, Del 
Mar CB. Systemic corticosteroids for acute otitis media in children. 
CochraneDatabaseof SystematicReviews 2016, Issue 7. Art. No.: CD012289. DOI: 
10.1002/14651858.CD012289. 

12. eTG complete Therapeutic Guidelines Limited 2018, Acute otitis media, viewed 6 
December 2018,&lt; https://tgldcdp.tg.org.au/viewTopic?topicfile=ear-nose-throat-
infections&amp;guidelineName=Antibiotic#toc_d1e444&gt; 

13. The Royal Children s Hospital Melbourne, Clinical Practice Guidelines:Acute otitis 
media, viewed 6 December 2018, 
&lt;https://www.rch.org.au/search/?addsearch=acute%20otitis%20media&gt; 

14. National Institute for Health and Care Excellence (NICE) 2018,Otitis media 
(acute):antimicrobial prescribing, viewed 6 December 2018, 
&lt;https://www.nice.org.uk/guidance/ng91&gt; 

 

  







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Acknowledgements 
The South Australian Child and Adolsecent Health Community of Practice gratefully 
acknowledge the contribution of clinicians and other stakeholders who participated throughout 
the guideline development process, particularly:  

Write Group Lead 
Dr Sonja Latzel 

Write Group Members 
Dr David Wabnitz 
Ms Silvia O Connor 

SA Paediatric Clinical Practice Guideline Reference Group Members 

Document Ownership &amp; History 
Developed by: SA Child &amp; Adolescent Health Community of Practice 
Contact: Health.PaediatricClinicalGuidelines@sa.gov.au 
Endorsed by: Commissioning and Performance, SA Health  
Next review due: 11/06/2025  
ISBN number:  978-1-74243-896-2
PDS reference:  CG132
Policy history: Is this a new policy (V1)?   N

Does this policy amend or update and existing policy?   Y
If so, which version? V1
Does this policy replace another policy with a different title?  N
If so, which policy (title)?

Approval 
Date Version 

Who approved New/Revised 
Version Reason for Change 

02/07/20 V2.1 
Lynne Cowan, Deputy CE, 
Commissioning and Performance, SA 
Department for Health and Wellbeing 

To amend the management of 
children aged &gt;24 months, and 
amend the approval body and 
PDS reference number. 

11/06/20 V2 SA Safety and Quality Strategic 
Governance Committee 

Formally reviewed in line with 1-5 
year scheduled timeline for review. 

11/02/14 V1 SA Health Safety &amp; Quality Strategic Governance Committee 

Original SA Health Safety &amp; Quality 
Strategic Governance Committee 
approved version. 



	Purpose and Scope of PCPG
	Exclusions
	Flowchart: Suggested antibiotic usage for acute otitis media
	Diagram 1: Commencing antibiotics
	Table of Contents
	Summary of Practice Recommendations
	Abbreviations
	Definitions
	Acute otitis media in children
	Management
	Well children 6-24 months
	First line therapy:

	Complications
	Acute mastoiditis
	Chronic otitis media with effusion
	Bullous myringitis
	Infected tympanostomy tubes (grommets)
	References

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