Otitis Media

[2013 update]

Introduction to this self-study CME activity


Otitis media is one of the most common diagnoses made by pediatricians. However, a great deal of variability remains in diagnostic criteria, approaches to therapy, and follow-up. This self-study activity provides practical guidance to clinicians about diagnosing and treating otitis media based on available empirical evidence.

Key and newer aspects of care that are elaborated in the guideline include:

  • The diagnosis of acute otitis media (AOM) should be based on symptoms of fever and/or otalgia in conjunction with the identification of an inflammatory middle ear effusion.
  • Deferring antibiotic therapy should be considered for children age 2 and older with AOM and mild to moderate symptoms.
  • Analgesic therapy should be recommended for all children with AOM.
  • When antibiotic therapy is deferred, facilitate patient access to antibiotics if symptoms worsen (e.g., a "back-up" prescription given at visit or a convenient system for subsequent call-in).
  • For children with AOM unresponsive to high dose amoxicillin, either amoxicillin/clavulanate or high dose azithromycin are appropriate second line therapies.
  • Oral cephalosporins should not be used to treat AOM.
  • Referral to otolaryngology for otitis media with effusion (OME) should be based on apparent developmental or behavioral problems or concern for anatomic damage to middle ear structures, rather the simple duration of the effusion.

When medical antibiotic treatment is indicated:

  •  High dose amoxicillin is the first choice of antibiotic therapy for all cases of AOM. 

-  Children:

Dosing:  < 4 years, 80 mg/kg/day divided BID;  ≥ 4 years, 40- 60 mg/kg/day.

Duration 5- 10 days: 5 days is usually sufficient at lower cost and fewer side effects, although 10 days reduces clinical failure [A*]. Consider 10-day course for young children with significant early URI symptoms, children with possible sinusitis, and children with possible strep throat.

-  Adults:  either 875 mg BID x 10 days or 500 mg 2 tabs BID x 10 days.

  • Treat AOM that is clinically unresponsive to amoxicillin after 72 hours of therapy with either:

-  amoxicillin/clavulanate – pediatric 80 mg/kg divided BID x 10 days; adult 875/125 mg BID x 10 days

-  azithromycin – pediatric 20 mg/kg daily for 3 days; adult 1 g daily for 3 days

  • Patients with persistent symptoms on these agents should receive: ceftriaxone – pediatric 50-75 mg/kg/day IM x 1-3 days; adult 1-2g IM/IV daily x 1-3 days.  The decision to use ceftriaxone should take into account the possible impact of this antibiotic on patterns of antibiotic resistance. 
  • Decongestants and nasal steroids SHOULD NOT be used to treat middle ear effusions.


Participants in this CME activity will understand and be able to implement evidence-based cost-effective clinical strategies for the diagnosis and treatment of otitis media in children and adults.


This self-study activity is appropriate for primary care clinicians and other health care providers who diagnosis and treat otitis media in children and adults.


Team Leaders

  • Heather L. Burrows, MD, PhD
    General Pediatrics

Team Members

  • R. Alexander Blackwood, MD
    Pediatric Infectious Disease
  • James M. Cooke, MD
    Family Medicine
  • R. Van Harrison, PhD
    Medical Education
  • Kathryn M. Harmes, MD
    Family Medicine
  • Peter P. Passamani, MD
    Pediatric Otolaryngology


  • Kristin C. Klein, PharmD
    UMH Pharmacy Services

Author Disclosures

Neither the team lead, the team members, nor the consultants have financial relationships with commercial companies whose products are discussed in this CME activity.

Other Acknowledgements

UMHS Guidelines Oversight Team

  • Grant Greenberg, MD, MA, MHSA
  • R. Van Harrison, PhD

Literature Search Services

  • Taubman Medical Library

Production of Internet Format and Website Maintenance

  • Ellen Patrick-Dunlavey, MA

CME Accreditation and Credit Designation

The University of Michigan Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Michigan Medical School designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This CME activity was released in April 2013, with credit available through March 2016. The activity was reviewed for currency of content in April 2016 and availability of credit extended through April 2019. Continuation of credit from that date depends on a thorough review of the content currency and accuracy. 

Method of Participation

  1. View the web pages. You may print the self-study text to read off-line.
  2. Complete the on-line learning assessment test with a score of 70% or higher.  After you initially take the test, the test will be immediately electronically scored. 
    If fewer than 70% of the questions are answered correctly, the questions that were not answered correctly will be noted in red.  Review the CME content related to those topics and retake the test.
    If 70% or more of the questions are answered correctly, the correct and incorrect answers for all questions will be shown along with explanations of the basis for the correct answer.  The link to register and receive credit is shown at the end of the items and explanations. 
  3. Complete the electronic credit request and activity evaluation.  An electronic certificate of participation will be provided immediately.
  4. Print the certificate of participation for your personal records.