Initial diagnosis
The diagnosis of acute otitis media is based on the presence of inflammatory signs in the middle ear, particularly a moderately to severely bulging tympanic membrane or recent-onset otorrhea, provided that the discharge is not attributable to otitis externa.
Another possible diagnostic presentation is mild bulging of the tympanic membrane associated with recent-onset ear pain or marked erythema. The diagnosis should always integrate the clinical history and otoscopic findings.
Severity assessment
Once the diagnosis has been confirmed, the presence of criteria supporting immediate antibiotic treatment should be assessed. These include age younger than 6 months, severe clinical illness, bilateral otitis media in children younger than 2 years, the presence of otorrhea or episodes of recurrent acute otitis media.
Severe illness usually includes persistent moderate to severe ear pain, high fever or significant impairment of the child’s general condition.
Symptomatic treatment and observation
In the absence of these criteria, an initial strategy of symptomatic treatment combined with clinical observation may be adopted. Analgesia may be provided with paracetamol or ibuprofen, adjusted to body weight.
In these cases, clinical reassessment after 48–72 hours is recommended, particularly if symptoms worsen or persist.
First-line antibiotic treatment
If signs or symptoms compatible with acute otitis media persist at reassessment, antibiotic treatment should be started.
First-line treatment is oral amoxicillin 80–90 mg/kg/day, administered every 12 hours, for 5 days.
In children younger than 2 years, those with recurrent acute otitis media or initial treatment failure, the duration should be extended to 7 days.
Second-line treatment
When there is treatment failure with amoxicillin, amoxicillin use during the previous 30 days or suspected infection with beta-lactamase-producing organisms, the preferred option is amoxicillin–clavulanate, using the same dosing schedule.
Alternatives include oral cefuroxime or, when parenteral treatment is required, intramuscular ceftriaxone as a single dose or for three days, depending on the clinical course.
Penicillin allergy
In children with type I hypersensitivity to penicillin, clarithromycin, erythromycin or azithromycin may be used, with the duration adjusted to clinical severity.
In cases of non-type I hypersensitivity, oral cefuroxime remains a safe alternative.
Treatment failure
If symptoms persist or worsen after 48–72 hours of antibiotic therapy, a new clinical assessment is required.
At this stage, the diagnosis should be reassessed, alternative diagnoses excluded and signs of complications actively sought.
Complications
Progression to mastoiditis, labyrinthitis, petrositis or intracranial complications, including meningitis, abscesses, venous thrombosis or empyema, requires urgent referral for hospital and otorhinolaryngology assessment.
When no complications are present but active disease persists, treatment escalation should be considered. If acute otitis media is not confirmed, other causes of the clinical presentation should be considered.
