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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Very common in children (peak 6–18 months) — usually follows a viral URTI
- Diagnosis: otalgia + bulging, erythematous tympanic membrane on otoscopy
- Most cases resolve without antibiotics (viral or self-limiting bacterial) — NICE recommends delayed/back-up prescription
- Immediate antibiotics: <3 months old, systemically unwell, bilateral AOM in <2 years, perforation with discharge, immunocompromised
- First-line antibiotic: amoxicillin for 5–7 days. Complications: mastoiditis (tender, red swelling behind ear), meningitis, intracranial abscess
Overview
Acute otitis media is an infection of the middle ear space, extremely common in young children. It typically follows a viral upper respiratory tract infection causing Eustachian tube dysfunction and secondary bacterial infection. The most common bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. The tympanic membrane appears bulging, erythematous, and may perforate with mucopurulent discharge. The vast majority resolve spontaneously within 72 hours.
Epidemiology
AOM is one of the most common reasons for GP consultations and antibiotic prescriptions in children. By age 3, approximately 80% of children will have had at least one episode. Peak incidence is 6–18 months. Risk factors include: age <2 years, nursery attendance, bottle feeding (vs breastfeeding), parental smoking, dummy use, cleft palate, and Down syndrome.
Clinical Features
Symptoms
Ear pain (otalgia) — child may pull or tug at the ear
Fever
Irritability, poor feeding, disrupted sleep (young children)
Hearing loss (temporary — middle ear effusion)
Ear discharge (if tympanic membrane perforates) — pain typically improves after perforation
Swelling, redness, and tenderness behind the ear (mastoiditis)
Signs
Otoscopy: bulging, erythematous tympanic membrane — the key diagnostic finding
Loss of light reflex on TM
TM perforation with mucopurulent discharge in the ear canal
Fluctuant, tender swelling behind the pinna (mastoiditis — pushing pinna forward and outward)
Investigations
First-line
Clinical diagnosisBased on history and otoscopic examination — no investigations needed in uncomplicated cases
Second-line
TympanometryFlat (type B) trace suggests middle ear effusion — useful for persistent OME (glue ear)
Ear swabIf discharge present and not responding to first-line antibiotics — guide antibiotic choice
Specialist
CT temporal boneIf mastoiditis or intracranial complication suspected
AudiometryIf persistent hearing loss after resolution of acute infection (>3 months) — assess for OME/glue ear
Management
NICE NG91 (Otitis media), 20181
Conservative (most cases)
- Analgesia: regular paracetamol and/or ibuprofen
- Reassurance: most episodes resolve within 72 h without antibiotics
- Delayed/back-up prescription strategy: prescribe antibiotics but advise to only use if symptoms not improving after 3 days
2
Immediate antibiotics (indicated if)
- Age <3 months with temperature ≥38°C
- Systemically unwell or high fever
- Bilateral AOM in children <2 years
- AOM with perforation and purulent discharge
- Immunocompromised
- First-line: amoxicillin for 5–7 days
- Penicillin allergy: clarithromycin or erythromycin
3
Complications requiring urgent action
- Acute mastoiditis: IV antibiotics (IV co-amoxiclav or ceftriaxone) ± mastoidectomy — ENT emergency
- If intracranial complication suspected (meningitis, abscess): urgent CT head and neurosurgical/ENT input
4
Recurrent AOM and OME (glue ear)
- Recurrent AOM (≥3 episodes in 6 months or ≥4 in 12 months): ENT referral, consider grommets
- Persistent OME (>3 months) with hearing loss: audiology assessment, consider grommets
- Grommets: ventilation tubes through TM — improve hearing and reduce frequency of infections
Complications
- Acute mastoiditis: Most common complication — tender, erythematous swelling behind the pinna pushing it forward. Requires IV antibiotics ± surgery
- TM perforation: Usually heals spontaneously. Persistent perforation may need surgical repair (myringoplasty)
- OME (glue ear): Persistent middle ear effusion causing conductive hearing loss — affects speech development if bilateral in young children
- Intracranial complications: Meningitis, extradural/subdural abscess, sigmoid sinus thrombosis — rare but serious
- Facial nerve palsy: Middle ear inflammation affecting CN VII in its bony canal — usually recovers
UKMLA Exam Tips
- 1Most AOM does NOT need antibiotics — delayed prescription is the NICE-recommended strategy
- 2Immediate antibiotics: age <3 months, systemically unwell, bilateral <2 years, perforation with discharge, immunocompromised
- 3Bulging TM is the most important otoscopic finding — erythema alone (e.g. from crying) is insufficient for diagnosis
- 4Mastoiditis: tender, red swelling behind the ear pushing pinna forward + unwell child → emergency IV antibiotics and ENT referral
- 5Glue ear (OME) persisting >3 months with hearing loss → consider grommets — prevents speech delay
- 6AOM vs otitis externa: AOM = TM abnormal, canal normal. OE = canal inflamed, TM usually normal (tragal tenderness in OE)
practicetest your knowledge on acute otitis mediaApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — ent and beyond.
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Acute Otitis Media: guidance by region
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