Refer to an ear, nose, and throat (ENT) specialist if a patient with recurrent acute otitis media has recurrent episodes that are unexplained, very distressing, or associated with complications NICE CKS.
Consider referral for all people with recurrent AOM, especially if the episodes are very distressing or if complications are present NICE CKS.
Refer urgently within 2 weeks using a suspected cancer pathway if nasopharyngeal cancer is suspected, particularly in adults with persistent symptoms or signs such as conductive hearing loss, cervical lymphadenopathy, epistaxis, or nasal obstruction NICE CKS.
Referral should also be considered if recurrent episodes are associated with craniofacial abnormalities (e.g., Down's syndrome or cleft palate) NICE CKS.