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# Acute otitis media

Acute otitis media is an infection of the middle ear behind the eardrum, usually after a cold; it causes ear pain and fever, mostly in young children.

Updated 2026-10-30

## Structures involved

Tap one to see what it is and open it in 3D.

- [Eardrum](https://durgical.com/en/anatomy/tympanic-membrane/)
- [Auditory tube](https://durgical.com/en/anatomy/auditory-tube/)
- [Malleus](https://durgical.com/en/anatomy/malleus/)
- [Incus](https://durgical.com/en/anatomy/incus/)
- [Facial nerve (VII)](https://durgical.com/en/anatomy/facial-nerve/)
- [Temporal bones](https://durgical.com/en/anatomy/temporal-bone/)

## Microorganisms that cause it

- [Moraxella catarrhalis](https://durgical.com/en/microbiology/moraxella-catarrhalis/)
- [Haemophilus influenzae](https://durgical.com/en/microbiology/haemophilus-influenzae/)
- [Streptococcus pneumoniae](https://durgical.com/en/microbiology/streptococcus-pneumoniae/)

## In embryology

- [Pharyngeal pouches: tonsil, thymus, parathyroids and C cells](https://durgical.com/en/embryology/pharyngeal-pouches-tonsil-thymus-parathyroids-and-c-cells/)
- [Cleft lip and cleft palate](https://durgical.com/en/embryology/cleft-lip-and-cleft-palate/)

## In the clinical exam

- [Otoscopy and the Rinne and Weber tests](https://durgical.com/en/clinical-exam/otoscopy-and-the-rinne-and-weber-tests/)

## In physiology

- [Hearing: middle ear, cochlea and auditory pathway](https://durgical.com/en/physiology/hearing-middle-ear-cochlea-and-auditory-pathway/)

## Why it happens

- [Patterns of acute inflammation: serous, fibrinous, purulent, abscess, ulcer](https://durgical.com/en/general-pathology/patterns-of-acute-inflammation-serous-fibrinous-purulent-abscess-ulcer/)

## What it is

Acute infection of the middle ear with fluid behind a bulging, inflamed eardrum, usually following a cold. It is one of the commonest reasons young children see a doctor and receive antibiotics.

## Who gets it

Most frequent between about 6 months and 2 years of age and in children who attend day care. Pneumococcal conjugate vaccination, part of Colombia's national schedule, has reduced the burden: from 2008 to 2016, otitis media incidence in children under 2 fell 42.1–51.1% in Bogotá and Medellín after its introduction, though it rose in Barranquilla.

## Causes

- Streptococcus pneumoniae
- Non-typeable Haemophilus influenzae
- Moraxella catarrhalis
- Respiratory viruses, alone or preceding bacterial infection

## Risk factors

- Young age: the [auditory tube](https://durgical.com/en/anatomy/auditory-tube/) is shorter, wider and more horizontal
- Day care and siblings (more viral colds)
- Exposure to tobacco smoke
- Bottle feeding lying down; not breastfed
- Enlarged adenoids
- Cleft palate, Down syndrome, immunodeficiency

## Pathophysiology

A viral upper respiratory infection inflames the nasopharynx and auditory tube, which stops draining and ventilating the middle ear. Negative pressure draws in secretions and nasopharyngeal bacteria; the trapped fluid becomes infected and pus under pressure makes the eardrum bulge and may perforate it.

## Symptoms and signs

- Ear pain; in infants, ear pulling, irritability, crying and poor sleep
- Fever
- Reduced hearing on the affected side
- Discharge from the ear if the eardrum perforates (pain often eases)
- Preceding runny nose and cough

## Red flags

- Swelling, redness or tenderness behind the ear, with the ear pushed forward (mastoiditis)
- Facial weakness, vertigo or new marked hearing loss
- Severe headache, neck stiffness, drowsiness or seizures
- Infant under 6 months who looks unwell or has high fever

## Diagnosis

**Clinical**
Otoscopy is key: a moderately to severely bulging [eardrum](https://durgical.com/en/anatomy/tympanic-membrane/), or mild bulging with recent ear pain or intense redness, or new discharge not due to otitis externa. Pneumatic otoscopy shows poor eardrum movement. Middle-ear fluid without acute signs is otitis media with effusion.

**Tests**
Not routine. Tympanometry confirms middle-ear fluid; culture of discharge or of fluid from tympanocentesis in recurrent or treatment-failure cases.

**Imaging**
Not needed in uncomplicated cases. Contrast CT of the [temporal bone](https://durgical.com/en/anatomy/temporal-bone/), or MRI, when mastoiditis or an intracranial complication is suspected.

## Differential diagnosis

- Otitis media with effusion
- Otitis externa
- Referred ear pain (teeth, throat, [temporomandibular joint](https://durgical.com/en/anatomy/temporomandibular-joint/))
- Cholesteatoma
- Eardrum redness from crying or fever alone

## Goal of treatment

Relieve pain, let most cases settle on their own, use antibiotics where they help most, and detect complications early.

## Treatment

**Medical**
Pain relief with analgesics (paracetamol class) or NSAIDs in every case, whatever the antibiotic decision.

**Follow-up**
Watchful waiting with assured follow-up in selected children older than 6 months with non-severe illness; antibiotics start if there is no improvement within 2–3 days. Criteria vary between guidelines.

**Medical**
Antibiotics for younger infants, severe or bilateral disease, or discharge: aminopenicillins first line, with a beta-lactamase inhibitor after recent treatment or failure; cephalosporins or macrolides in penicillin allergy.

**Procedure**
Tympanostomy (ventilation) tubes considered for recurrent acute otitis media or persistent effusion with hearing loss.

## Drugs for this condition

- [Amoxicillin + clavulanic acid](https://durgical.com/en/pharmacology/amoxicillin-clavulanic-acid/)
- [Cefalexin](https://durgical.com/en/pharmacology/cefalexin/)
- [Cefixime](https://durgical.com/en/pharmacology/cefixime/)
- [Cefuroxime](https://durgical.com/en/pharmacology/cefuroxime/)
- [Amoxicillin](https://durgical.com/en/pharmacology/amoxicillin/)

## Complications

- Eardrum perforation
- Persistent middle-ear effusion with conductive hearing loss and speech delay
- Acute mastoiditis
- [Facial nerve](https://durgical.com/en/anatomy/facial-nerve/) palsy, labyrinthitis
- Meningitis, brain abscess, [sigmoid sinus](https://durgical.com/en/anatomy/sigmoid-sinus/) thrombosis (rare)
- Chronic suppurative otitis media

## Prognosis

Most episodes resolve within a few days, many without antibiotics. Middle-ear fluid can last for weeks after the infection settles. Serious complications are now rare where follow-up and vaccination are good.

## Prevention

- Pneumococcal conjugate and influenza vaccination
- Breastfeeding
- Avoiding tobacco smoke exposure
- Not bottle feeding lying flat

## Test yourself

Think of the answer, then tap the question to see it.

## Which otoscopic finding best supports a diagnosis of acute otitis media?

A bulging tympanic membrane (moderate to severe, or mild with recent pain or intense redness).

## Why are young children more prone to acute otitis media?

Their auditory tube is shorter, wider and more horizontal, so it drains and ventilates the middle ear poorly.

## Which three bacteria cause most acute otitis media?

Streptococcus pneumoniae, non-typeable Haemophilus influenzae and Moraxella catarrhalis.

## What is the antibiotic class of first choice for acute otitis media?

Aminopenicillins, with a beta-lactamase inhibitor after recent antibiotics or treatment failure.

## Which complication causes swelling behind the ear and pushes the auricle forward?

Acute mastoiditis.

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## Related conditions

- [Acute rhinosinusitis](https://durgical.com/en/conditions/acute-rhinosinusitis/)
- [Streptococcal pharyngitis](https://durgical.com/en/conditions/streptococcal-pharyngitis/)
- [Bacterial meningitis](https://durgical.com/en/conditions/bacterial-meningitis/)
- [Otitis externa](https://durgical.com/en/conditions/otitis-externa/)
- [Bell palsy](https://durgical.com/en/conditions/bell-palsy/)
- [Allergic rhinitis](https://durgical.com/en/conditions/allergic-rhinitis/)
- [Temporomandibular disorder](https://durgical.com/en/conditions/temporomandibular-disorder/)
- [Cleft lip and palate](https://durgical.com/en/conditions/cleft-lip-and-palate/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Acute Otitis Media](https://www.ncbi.nlm.nih.gov/books/NBK470332/) (StatPearls (NCBI Bookshelf), 2026); [Trends in all-cause pneumonia and otitis media in children aged

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/conditions/acute-otitis-media/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/acute-otitis-media/