• Treatment is based on careful diagnosis (see Diagnosis of otitis media: definitions and workup (Diagnosis of otitis media: symptoms, clinical examination and findings). If acute otitis media (AOM) is only suspected, antimicrobial drugs are not indicated.
• Treatment is always individual: AOM often resolves without antimicrobials [Evidence Level: A] but antimicrobials may hasten recovery (fever and ear pain).

• Analgesics should always be given.
  • Pain evaluation is difficult with small children.
  • In addition to paracetamol (15–20 mg/kg 4 times daily, no more than 60 mg/kg/day, for children from neonates),
    • ibuprofen (10 mg/kg 3 times daily for children ≥ 3 months) or
    • naproxen (5 mg/kg twice daily for children ≥ 12 months).
  • Anaesthetic ear drops, as necessary [Evidence Level: B] (cinchocaine, available without prescription).
• Before an antimicrobial drug is started, each case should be considered individually.
  • Take into account the severity of the illness, any adverse effects of the drugs (diarrhoea and increased resistance) and the parents’ wishes.
  • An antimicrobial drug should be started if spontaneous perforation has occurred or if there is severe bulging of the tympanic membrane.
    • A bacterial culture sample of secretions from the perforated tympanic membrane should be taken and the antimicrobial treatment specified depending on the results.
    • Antimicrobial medication will cause fever and ear pain to subside more quickly.
    • There is conflicting evidence regarding the impact of antimicrobial treatment on the duration of middle ear effusion.
• If antimicrobial medication is started
  • The first choice drug is either amoxicillin at a dose of 40 mg/kg/day or amoxicillin/clavulanic acid 40 mg/5.7 mg/kg/day, each divided into 2 daily doses.
  • Amoxicillin/clavulanic acid is also effective against beta lactamase producing bacteria (Moraxella catarrhalis and some Haemophilus influenzae strains).
  • A double dose of amoxicillin is effective against pneumococci with decreased sensitivity.
  • If oral medication cannot be used due to vomiting, for instance, 50 mg/kg/day of i.m. ceftriaxone can be used for 1–3 days.
  • In penicillin allergy, e.g. sulpha-trimethoprim at a dose of 25 mg/8 mg/kg/day divided into 2 daily doses, or a macrolide, is an alternative.
    • Sulpha, however, must not be used in the treatment of spontaneous perforation, since sulpha is not effective against Streptococcus pyogenes bacteria, which cause the most complications.
    • Macrolides have no effect on Haemophilus influenzae bacteria.
  • The usual duration of the antimicrobial treatment is 5 to 7 days.
• If antimicrobial pharmacotherapy is not started
  • Re-examination is not routinely required. It should be arranged if the parents are worried about the child's health or the symptom picture has changed.
  • Delayed prescribing of antimicrobials [Evidence Level: A] (the prescription is issued but the parents are advised only to start medication if the child shows no clear signs of recovery within 2–3 days) is an alternative.
    • This way, the use of antimicrobials can be reduced, as some children recover without them.
    • Delayed starting of medication does not diminish the effect of the treatment but the waiting time may extend the child’s symptoms by, on average, 1–2 days.
• Myringotomy (tympanocentesis) does not promote healing.
  • It is indicated in some cases in order to clarify aetiology or if the pain is exceptionally severe and not relieved by appropriate pain medication.

Follow-up

• Routine follow-up examination is no longer recommended.
• The purpose of a potential follow-up examination is to check that the effusion does not persist for too long.
• It is normal for middle ear effusion to persist for as long as several weeks after AOM [Evidence Level: A].
  • The effusion may cause a slight decrease in hearing ability which will return to normal when the middle ear effusion has disappeared. The effusion does not usually cause any other harm.
• The need for and timing of a follow-up examination should be considered individually.
  • A follow-up examination should be done in 1–2 months if
    • there is a history of recurrent otitis media
    • a child < 12 months has bilateral otitis media
    • language development is significantly delayed
    • hearing impairment has been diagnosed previously or
    • there is an underlying condition that may increase the risk of prolonged middle ear effusion (such as Down’s syndrome, cleft palate, midfacial hypoplasia).
• If considered appropriate, follow-up examination may be carried out by tympanometry alone (Tympanometry).
• If the effusion has persisted for more than 3 months, the child should be referred to an ear specialist for assessment.

• An existing or suspected complication (e.g. mastoiditis, facial paralysis): requires emergency referral to an otorhinolaryngologist in specialized care.
• Referral to specialized care should be considered in the following situations:
  • Symptomatic inflammation persists uninterrupted despite second-line antimicrobial (urgent referral)
  • There are frequent episodes of AOM (≥ 4 episodes/6 months or ≥ 5 episodes/12 months; non-urgent referral); see Recurrent acute otitis media and its prevention (Recurrent acute otitis media and its prevention).
  • There is recurring purulent discharge from a tympanostomy tube or perforation.
  • Purulent ear discharge continues for more than a week despite appropriate treatment.
  • Middle ear effusion persists for more than 3 months (non-urgent referral); see Otitis media with effusion (glue ear) (Otitis media with effusion (glue ear)).
  • The child has pre-existing significant hearing impairment (urgency rating as considered appropriate).
  • A child < 3 months of age (urgency rating as considered appropriate).