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ent.otitis-media.core.v1PRODUCTION
ent.otitis-media.core.v1

Acute otitis media (ENT/EM lens)

general_internal_medicineacutesubacuteadultpediatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame AOM as middle-ear effusion PLUS acute inflammation, lifespan but pediatric-predominant. The two managed decisions are (1) observation vs immediate antibiotic and (2) the antibiotic ladder + mandatory analgesia. OME (effusion without inflammation — not an antibiotic disease) and otitis externa (canal disease — topical, routed OUT) are explicitly out of the antibiotic frame. Suppurative complications (mastoiditis, facial palsy, labyrinthitis, intracranial extension, sepsis) are recognised and routed OUT by engine_id, not re-managed here.

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AOM antibiotic frame confirmed; OME/OE and complication-routing scope set

Patient inputs (17)

Marked TM erythema and/or otalgia/distinct ear-tugging defines the "acute inflammation" half of AOM; effusion WITHOUT these is OME (not an antibiotic disease) (AAP 2013 Lieberthal; Rothman JAMA 2003 — distinctly red TM LR+ 8.4, normal colour LR− 0.2)

Bilateral AOM (esp. <2 y) shifts the observation-vs-antibiotic decision toward immediate antibiotics and confers the largest treatment benefit (AAP 2013; Hoberman NEJM 2011; Venekamp Cochrane 2023 — antibiotics most beneficial <2 y bilateral)

Otorrhoea (through perforation, no tube) marks more severe AOM with the largest absolute antibiotic benefit and removes the observation option (AAP 2013; Venekamp Cochrane 2023 — AOM+otorrhoea high-benefit subgroup)

Temperature ≥39 °C is a severe-AOM criterion and feeds the toxic-child / pediatric-fever screen (AAP 2013; workup.pediatric_fever)

Age is the master switch of the AAP 2013 algorithm: <6 mo always antibiotic; 6-23 mo bilateral / any severe → antibiotic; ≥2 y nonsevere unilateral → observation option (AAP 2013 Lieberthal)

Bulging/cloudy/immobile TM is the single strongest AOM sign and the AOM-vs-OME pivot; the AAP 2013 stringent definition requires moderate/severe bulge OR new otorrhoea (Rothman JAMA 2003 — bulging adjusted LR+ 51; AAP 2013 Lieberthal)

MEE (impaired pneumatic-otoscopy mobility, air-fluid level, type-B tympanogram) is necessary for AOM AND for OME; its presence with vs without acute inflammation is the AOM/OME discriminator (AAP 2013 Lieberthal; Rothman JAMA 2003 — immobile TM LR+ 31)

Post-auricular erythema/tenderness/fluctuance, protruding auricle, loss of post-auricular crease → acute mastoiditis; recognise and route OUT for ENT/drainage (AAP 2013; Cushen BJGP 2020 — incidence ~5.6/10 000 AOM)

Meningism, altered consciousness, focal deficit, seizures, facial palsy, or vertigo/SNHL → intracranial extension / facial-nerve / labyrinthine complication; route OUT (AAP 2013; Cushen BJGP 2020 — brain abscess ~0.03/10 000)

Severe AOM (moderate/severe otalgia, otalgia ≥48 h, or temperature ≥39 °C) mandates immediate antibiotics at any age — removes the observation option (AAP 2013 Lieberthal)

Amoxicillin within 30 days (or concurrent purulent conjunctivitis) selects amoxicillin-clavulanate over plain amoxicillin for β-lactamase coverage (AAP 2013 Lieberthal — conjunctivitis-otitis syndrome ≈ H. influenzae)

Penicillin allergy gates the entire β-lactam ladder to cefdinir/cefuroxime/cefpodoxime (non-severe) or azithromycin/clindamycin or ceftriaxone (severe) (AAP 2013 Lieberthal)

Weight-based dosing — high-dose amoxicillin 80-90 mg/kg/day divided BID is weight-driven (AAP 2013 Lieberthal)

Cleft palate / craniofacial anomaly / Down syndrome / immunocompromise / cochlear implant lowers the observation threshold and the ENT-referral threshold (AAP 2013 Lieberthal — excluded from the observation option)

Recurrent AOM (≥3 episodes/6 mo or ≥4/12 mo with ≥1 in the prior 6 mo) with a middle-ear effusion present is the tympanostomy-tube referral trigger and the FOLLOWUP recurrence-prevention input (AAO-HNS Rosenfeld 2022; Venekamp Cochrane 2018 — tubes vs active monitoring NNT ~3 at 6 mo)

Tube/perforation in situ converts management to TOPICAL ototopical antibiotic drops only (no oral) for uncomplicated otorrhoea (AAO-HNS Rosenfeld 2022 KAS14)

Adult/adolescent AOM antibiotic-safety gating — amoxicillin/amox-clav are pregnancy-safe; avoid doxycycline; azithromycin acceptable in true penicillin allergy (AAP 2013; standard antimicrobial pregnancy safety)

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Severity triggers (8)

8 need judgement
  • informationallife_threateningintracranial_extension_route_out
    AOM/mastoiditis + meningism, altered consciousness, focal deficit, seizure, or papilloedema = meningitis / sigmoid-or-lateral sinus thrombosis / epidural or brain abscess (Cushen BJGP 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningtoxic_child_or_sepsis_route_to_sepsis
    qSOFA ≥2, ill/toxic appearance, or hypotension on adequate fluids with an otogenic source (SSC 2021; AAP 2013 severe-AOM overlap)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_mastoiditis_route_out
    Post-auricular erythema/tenderness/fluctuance, protruding auricle, loss of the post-auricular crease ± systemic toxicity = acute mastoiditis (AAP 2013; Cushen BJGP 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereotogenic_facial_nerve_palsy
    Acute peripheral (House-Brackmann) facial-nerve weakness in the setting of AOM/mastoiditis (AAP 2013 — AOM complication, not idiopathic Bell palsy)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresuppurative_labyrinthitis
    Acute vertigo, spontaneous nystagmus, and sensorineural hearing loss complicating AOM/mastoiditis (AAP 2013 — labyrinthine complication)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatetreatment_failure_at_48_72h
    No improvement or worsening of otalgia/fever at 48-72 h on appropriate analgesia ± antibiotic (AAP 2013; Tähtinen NEJM 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesevere_aom_immediate_antibiotic
    Moderate/severe otalgia, otalgia ≥48 h, or temperature ≥39 °C — severe AOM at any age (AAP 2013 Lieberthal)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildrecurrent_aom_tube_referral
    Recurrent AOM ≥3 episodes/6 mo or ≥4/12 mo with ≥1 in the prior 6 mo, with a middle-ear effusion present at assessment (AAO-HNS Rosenfeld 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

AOM — analgesia (always) + observe-vs-antibiotic decision + escalation ladder
axis: aom_observe_vs_antibiotic_ladderstep 1 - Step 1 — Mandatory analgesia (every patient, every decision branch)
Selected step "Step 1 — Mandatory analgesia (every patient, every decision branch)" — Any AOM regardless of whether an antibiotic is given — pain control is independent of and parallel to the antibiotic decision
  • ibuprofen
    first line
    NSAID
    10 mg/kg (max 400-600 mg adult) • PO • q6-8h PRN (max: 40 mg/kg/day (max 2.4 g/day))
    triggers: otalgia, age_over_6_months
    AAP 2013 Lieberthal — analgesia is a primary AOM recommendation independent of antibiotics; ibuprofen first-line for otalgia ≥6 mo
    rxcui 5640
  • acetaminophen
    first line
    analgesic_antipyretic
    15 mg/kg (max 1 g adult) • PO • q4-6h PRN (max: 75 mg/kg/day (max 4 g/day))
    triggers: otalgia, any_age
    AAP 2013 Lieberthal — acetaminophen first-line analgesia; usable <6 mo where NSAIDs are restricted
    rxcui 161
  • topical_anaesthetic_analgesic_ear_drops_if_TM_intact
    add on
    topical_analgesic
    triggers: intact_tm, older_child_or_adult, severe_otalgia
    NICE NG91 [2022] — anaesthetic/analgesic ear drops as adjunct when TM intact and no perforation; do NOT use if perforation/otorrhoea

outpatient playbook — drug actions (5)

  1. 1. ibuprofen (analgesia, every patient ≥6 mo)
    rxcui 5640
    10 mg/kg • PO • q6-8h PRN
    trigger: Otalgia — analgesia is independent of the antibiotic decision (AAP 2013)
    Primary AAP 2013 recommendation; pair with/without antibiotics
  2. 1. acetaminophen (analgesia, any age incl <6 mo)
    rxcui 161
    15 mg/kg • PO • q4-6h PRN
    trigger: Otalgia, especially <6 mo where NSAIDs restricted (AAP 2013)
    First-line analgesic/antipyretic across the lifespan
  3. 2. high-dose amoxicillin (first-line antibiotic when indicated)
    rxcui 723
    80-90 mg/kg/day • PO • divided BID
    trigger: <6 mo; 6-23 mo bilateral/severe/otorrhoea; ≥2 y severe; observation failure (AAP 2013)
    Overcomes intermediate-resistant S. pneumoniae; Tähtinen NEJM 2011 effect
  4. 3. amoxicillin-clavulanate (recent amoxicillin / conjunctivitis-otitis / failure)
    rxcui 19711
    90 mg/kg/day amox component • PO • divided BID
    trigger: Amoxicillin within 30 d, purulent conjunctivitis, or 48-72 h failure (AAP 2013)
    β-lactamase coverage for H. influenzae / M. catarrhalis
  5. 4. cefdinir (non-severe penicillin allergy)
    rxcui 25037
    14 mg/kg/day • PO • once daily or BID
    trigger: Non-anaphylactic penicillin allergy (AAP 2013)
    Low side-chain cross-reactivity cephalosporin alternative

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute ear pain (ear-tugging/irritability in a preverbal child) often after/with a viral URI — the commonest AOM presentation (AAP 2013 Lieberthal; Rothman JAMA 2003 — ear pain LR+ 3.0-7.3); New acute purulent otorrhoea through a perforated TM (NOT a swimmer / canal-traction-tender ear) — AOM with perforation; one AAP 2013 diagnostic pathway by itself; Bulging / cloudy / distinctly immobile TM on (pneumatic) otoscopy — the strongest objective AOM finding (Rothman JAMA 2003 — bulging adjusted LR+ 51, cloudy 34, immobile 31).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute otitis media (ENT/EM lens)** (ent.otitis-media.core.v1).
Phenotype framing: Terminal differential with named pivots: AOM vs OME (acute inflammation + moderate/severe bulge + otalgia/fever pivot — Rothman JAMA 2003 bulging LR+ 51) vs otitis externa (tragal/pinna-traction tenderness + canal oedema/debris + normal-or-obscured TM pivot — route to ent.otitis-externa.core.v1) vs bullous myringitis (haemorrhagic TM bullae — managed as AOM) vs referred otalgia (normal ear exam + extra-otologic source: pharyngitis/dental/TMJ/cervical spine pivot) vs mastoiditis (post-auricular swelling + protruding pinna pivot — route OUT).
Scope: Frame AOM as middle-ear effusion PLUS acute inflammation, lifespan but pediatric-predominant. The two managed decisions are (1) observation vs immediate antibiotic and (2) the antibiotic ladder + mandatory analgesia. OME (effusion without inflammation — not an antibiotic disease) and otitis externa (canal disease — topical, routed OUT) are explicitly out of the antibiotic frame. Suppurative complications (mastoiditis, facial palsy, labyrinthitis, intracranial extension, sepsis) are recognised and routed OUT by engine_id, not re-managed here.

No severity triggers fired against current inputs.

Plan

Regimen axis: **AOM — analgesia (always) + observe-vs-antibiotic decision + escalation ladder** — step "Step 1 — Mandatory analgesia (every patient, every decision branch)".
1. ibuprofen 10 mg/kg (max 400-600 mg adult) PO q6-8h PRN (NSAID, first line) — AAP 2013 Lieberthal — analgesia is a primary AOM recommendation independent of antibiotics; ibuprofen first-line for otalgia ≥6 mo
2. acetaminophen 15 mg/kg (max 1 g adult) PO q4-6h PRN (analgesic_antipyretic, first line) — AAP 2013 Lieberthal — acetaminophen first-line analgesia; usable <6 mo where NSAIDs are restricted
3. topical_anaesthetic_analgesic_ear_drops_if_TM_intact (topical_analgesic, add on) — NICE NG91 [2022] — anaesthetic/analgesic ear drops as adjunct when TM intact and no perforation; do NOT use if perforation/otorrhoea

Setting playbook (outpatient) — Make the AOM-vs-OME-vs-OE diagnosis on otoscopy, control pain in every patient, apply the AAP 2013 observe-vs-antibiotic decision with a 48-72 h safety net, and refer recurrent AOM to ENT for tube candidacy (AAP 2013 Lieberthal; NICE NG91; AAO-HNS Rosenfeld 2022)
4. ibuprofen (analgesia, every patient ≥6 mo) 10 mg/kg PO q6-8h PRN — Otalgia — analgesia is independent of the antibiotic decision (AAP 2013) (Primary AAP 2013 recommendation; pair with/without antibiotics)
5. acetaminophen (analgesia, any age incl <6 mo) 15 mg/kg PO q4-6h PRN — Otalgia, especially <6 mo where NSAIDs restricted (AAP 2013) (First-line analgesic/antipyretic across the lifespan)
6. high-dose amoxicillin (first-line antibiotic when indicated) 80-90 mg/kg/day PO divided BID — <6 mo; 6-23 mo bilateral/severe/otorrhoea; ≥2 y severe; observation failure (AAP 2013) (Overcomes intermediate-resistant S. pneumoniae; Tähtinen NEJM 2011 effect)
7. amoxicillin-clavulanate (recent amoxicillin / conjunctivitis-otitis / failure) 90 mg/kg/day amox component PO divided BID — Amoxicillin within 30 d, purulent conjunctivitis, or 48-72 h failure (AAP 2013) (β-lactamase coverage for H. influenzae / M. catarrhalis)
8. cefdinir (non-severe penicillin allergy) 14 mg/kg/day PO once daily or BID — Non-anaphylactic penicillin allergy (AAP 2013) (Low side-chain cross-reactivity cephalosporin alternative)

Non-pharmacologic actions:
- Document otoscopy (bulging/cloudy/erythema/effusion/perforation) and the AOM/OME/OE call (AAP 2013)
- Shared decision with caregiver for the observation option; issue a safety-net (delayed) prescription with explicit fill instructions (NICE NG91; AAP 2013)
- Topical anaesthetic ear drops only if TM intact / no perforation (NICE NG91 [2022])
- Counsel: post-AOM effusion persists for weeks and is OME, not relapse — do not re-treat (AAP 2013; AAO-HNS Rosenfeld 2022)
- Modifiable-risk counselling: no supine bottle-feeding, avoid tobacco smoke, ensure pneumococcal/influenza vaccination (AAP 2013)

AVOID / contraindication checks:
- Penicillin anaphylaxis block amoxicillin amoxclav and cephalosporins (AAP 2013 — severe allergy → azithromycin/clindamycin, not a cephalosporin)
- Non severe penicillin allergy allows cefdinir cefuroxime cefpodoxime (AAP 2013 — low side chain cross reactivity)
- Tube or perforation topical only no oral for uncomplicated otorrhoea (AAO HNS Rosenfeld 2022 KAS14)
- No antibiotic for OME effusion without acute inflammation (AAP 2013 — OME is not an antibiotic disease; AAO HNS Rosenfeld 2022)
- Avoid doxycycline in pregnancy and young children (standard antimicrobial pregnancy/pediatric safety; not an AOM first line anyway)
- 5 day course inferior under 2y use 10 day (Hoberman NEJM 2016 — clinical failure 34% vs 16%)

Monitoring

Regimen monitoring:
- symptom reassessment at 48-72h treatment failure if no improvement (AAP 2013; Tähtinen NEJM 2011)
- safety net delayed prescription filled only if no improvement or worsening 48-72h (AAP 2013; NICE NG91)
- post AOM effusion persists weeks is OME not relapse do not re-treat (AAP 2013; AAO-HNS Rosenfeld 2022)
- recurrent AOM 3in6 or 4in12 with MEE present then ENT tube referral (AAO-HNS Rosenfeld 2022; Venekamp Cochrane 2018)
- antibiotic adverse event NNH 14 counsel diarrhoea rash vomiting (Venekamp Cochrane 2023)

Setting (outpatient) monitoring:
- Reassess at 48-72 h (in person or by reliable caregiver report) for improvement vs treatment failure (AAP 2013)
- Return precautions: worsening otalgia/fever, post-auricular swelling, facial droop, vertigo, neck stiffness, lethargy (AAP 2013; Cushen BJGP 2020)
- Audiology + OME pathway if effusion ≥3 mo or hearing concern (AAO-HNS Rosenfeld 2022)

Follow-up plan: Post-AOM hearing/effusion surveillance — persistent MEE ≥3 mo or hearing concern → audiology + OME pathway (AAO-HNS Rosenfeld 2022). Recurrent AOM (≥3/6 mo or ≥4/12 mo with ≥1 recent) with MEE present → ENT tympanostomy-tube referral (Venekamp Cochrane 2018 — tubes vs active monitoring NNT ~3 at 6 mo). Modifiable-risk counselling: avoid supine bottle-feeding, tobacco-smoke exposure, ensure pneumococcal + influenza immunisation; breastfeeding is protective (AAP 2013 prevention section).
- Close-out criterion: hearing/effusion surveillance + recurrence/prevention plan documented; ENT referral made if tube criteria met

Monitoring phase: Reassess at 48-72 h: expect symptomatic improvement; persistent or worsening otalgia/fever at 48-72 h on appropriate therapy = treatment failure → step up amoxicillin → amoxicillin-clavulanate → ceftriaxone × 3 d (and re-examine for missed OME-not-AOM, otitis externa, or an evolving complication before silently extending duration). Counsel that MEE persists for weeks after AOM resolves and is OME (not relapse) — do not re-treat asymptomatic post-AOM effusion (AAP 2013; AAO-HNS Rosenfeld 2022).

Disposition

Current setting: outpatient — Make the AOM-vs-OME-vs-OE diagnosis on otoscopy, control pain in every patient, apply the AAP 2013 observe-vs-antibiotic decision with a 48-72 h safety net, and refer recurrent AOM to ENT for tube candidacy (AAP 2013 Lieberthal; NICE NG91; AAO-HNS Rosenfeld 2022)

Disposition criteria:
- Discharge with analgesia ± antibiotic (immediate or safety-net delayed) and 48-72 h recheck advice if uncomplicated (AAP 2013)
- Refer to ENT for tube candidacy if recurrent AOM with effusion present (AAO-HNS Rosenfeld 2022)
- Escalate to ED / admit and route OUT if any suppurative complication or toxic child (AAP 2013)

Escalation triggers (move to higher acuity):
- No improvement / worsening at 48-72 h → step up the antibiotic ladder and re-examine for missed OME/OE/complication (AAP 2013)
- Mastoiditis / facial palsy / vertigo-SNHL / meningism / toxic appearance → ED + route OUT by engine_id (AAP 2013; Cushen BJGP 2020)
- Recurrent AOM meeting AAO-HNS criteria with MEE present → ENT tympanostomy-tube referral (AAO-HNS Rosenfeld 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] AOM/mastoiditis + meningism, altered consciousness, focal deficit, seizure, or papilloedema = meningitis / sigmoid-or-lateral sinus thrombosis / epidural or brain abscess (Cushen BJGP 2020)
- [LIFE_THREATENING] qSOFA ≥2, ill/toxic appearance, or hypotension on adequate fluids with an otogenic source (SSC 2021; AAP 2013 severe-AOM overlap)
- [SEVERE] Post-auricular erythema/tenderness/fluctuance, protruding auricle, loss of the post-auricular crease ± systemic toxicity = acute mastoiditis (AAP 2013; Cushen BJGP 2020)

Citations

- AAP 2013 AOM Clinical Practice Guideline (Lieberthal et al, Pediatrics 2013, PMID 23439909 — current US authority, no 2024-2026 replacement, WebSearch-verified 2026-05-17) + NICE NG91 Otitis media (acute): antimicrobial prescribing (2018, updated 2022, sepsis-link refresh Nov 2025) + AAO-HNS Tympanostomy Tubes in Children Update (Rosenfeld 2022, PMID 35138954) + Cochrane antibiotics-for-AOM (Venekamp 2023, PMID 37965923) + Rothman JAMA 2003 Rational Clinical Examination (otoscopy likelihood ratios) + Tähtinen/Hoberman NEJM 2011 placebo RCTs + 2024 Italian intersociety AOM consensus (freshness cross-check) [PMID:23439909](https://pubmed.ncbi.nlm.nih.gov/23439909/)
- Cited evidence (PMID 14506123) [PMID:14506123](https://pubmed.ncbi.nlm.nih.gov/14506123/)
- Cited evidence (PMID 21226577) [PMID:21226577](https://pubmed.ncbi.nlm.nih.gov/21226577/)
- Cited evidence (PMID 21226576) [PMID:21226576](https://pubmed.ncbi.nlm.nih.gov/21226576/)
- Cited evidence (PMID 28002709) [PMID:28002709](https://pubmed.ncbi.nlm.nih.gov/28002709/)

Last reconciled with current guidelines: 2026-05-17.
References
  • AAP 2013 AOM Clinical Practice Guideline (Lieberthal et al, Pediatrics 2013, PMID 23439909 — current US authority, no 2024-2026 replacement, WebSearch-verified 2026-05-17) + NICE NG91 Otitis media (acute): antimicrobial prescribing (2018, updated 2022, sepsis-link refresh Nov 2025) + AAO-HNS Tympanostomy Tubes in Children Update (Rosenfeld 2022, PMID 35138954) + Cochrane antibiotics-for-AOM (Venekamp 2023, PMID 37965923) + Rothman JAMA 2003 Rational Clinical Examination (otoscopy likelihood ratios) + Tähtinen/Hoberman NEJM 2011 placebo RCTs + 2024 Italian intersociety AOM consensus (freshness cross-check) — PMID:23439909
  • Cited evidence (PMID 14506123) — PMID:14506123
  • Cited evidence (PMID 21226577) — PMID:21226577
  • Cited evidence (PMID 21226576) — PMID:21226576
  • Cited evidence (PMID 28002709) — PMID:28002709