HOW TO TREAT 29 explored the views of parents and carers of urban Aboriginal and Torres Strait Islander children with AOM without perforation who were at low risk of complications. 54 Parents were supportive of watchful waiting if part of a shared decision-making process. 54
ausdoc. com. au 18 JULY 2025
HOW TO TREAT 29 explored the views of parents and carers of urban Aboriginal and Torres Strait Islander children with AOM without perforation who were at low risk of complications. 54 Parents were supportive of watchful waiting if part of a shared decision-making process. 54
A 2017 study looked at the current rate of antibiotic prescribing for acute respiratory infections in Australian general practice, finding that antibiotics were prescribed 4-9 times more than recommended by guidelines( eg, for acute rhinosinusitis, acute bronchitis / bronchiolitis, AOM and acute pharyngitis / tonsillitis). 55
A meta-analysis published in 2024 reviewed randomised controlled trials and observational studies comparing antibiotics with placebo or watchful waiting for paediatric AOM. This study found that prompt antibiotic therapy reduces the risk of some complications of AOM, such as acute mastoiditis( other evidence suggests 2500 children need to be treated to avoid one mastoiditis), but the number needed to harm because of adverse effects was relatively low. 56
Watchful waiting should not be interpreted as withholding care. Analgesia and supportive care are the mainstay of OM management plans, and antibiotics can always be started at a later date if resolution is slow.
Chronic suppurative otitis media
CSOM is defined by persistent pus discharge through a perforated tympanic membrane for more than 2-6 weeks, distinguishing it from AOM with perforation. 3, 37 CSOM is managed with thorough ear cleaning( ear toilet) and prolonged use of topical antibiotics, with weekly reviews until resolution( see figure 6). 3, 43
Persistent cases may require oral antibiotics or even hospital admission for IV treatment as undertreated CSOM can lead to lifelong damage to the middle ear cleft. Referral to ENT specialists and audiologists is essential for comprehensive care. Speech – language therapy is needed for children with associated speech, behavioural or learning difficulties. 3, 43 Given long wait times, many clinicians refer children with CSOM at presentation. Regular follow-ups and adherence to treatment are key to managing both AOM and CSOM effectively. 3, 43 A recent systematic review found low-quality evidence suggesting topical antibiotics may be slightly more effective than systemic antibiotics in resolving ear discharge in CSOM, with further robust studies needed. 57
Figure 7 offers an algorithm for the diagnosis and management of OM without discharge.
ENT specialist referral and management
Access to ENT specialists across Australia can be challenging, and not all children with OM will need a referral to a specialist. Specialist management is typically reserved for recurrent and prolonged cases, children at high risk of complications( eg, Aboriginal and Torres Strait islander children from remote settings) and those who have current hearing impairment( 20dB +), speech and language or global developmental delays. 3
Other cases that warrant specialist intervention include children with recurrent AOM, those with more serious complications( cholesteatoma [ see figure 8 ], mastoiditis or facial
Yes
Yes
nerve palsy), chronic perforations( eg, CSOM but also prolonged dry perforations). 3
In some cases, surgical interventions, such as tympanoplasty, to repair a chronic perforated eardrum, excision of cholesteatoma or the insertion of ventilation tubes may be required. Adenoidectomy or mastoidectomy might also be necessary depending on the severity of the condition. 3 While the use of ventilation tubes for chronic OME can improve hearing in the short
No discharge in the ear canal or next to the eardrum
No
Bulging eardrum or pain?
Three episodes of AOM in six months( or ≥4 in 12 months)?
Recurrent AOM
Effusion present for > 3 months?
Persistent bilateral OME
Persistent bilateral OME
OME persists & hearing uknown
Yes
No
AOM without perforation
Episodic bilateral OME
• Amoxicillin 50mg / kg / day as tds dosing for three weeks
• Autoinflation
• Audiology / hearing assessment
• ENT
• Monitor listening behaviour for signs of hearing loss
Mild to moderate hearing loss:
• Monthly review
• Communication strategies
• Audiological, speech – language and educational support
• Refer to ENT for grommet surgery
• Refer for hearing aid consult if surgery delayed > 6 months, unavailable or unsuccessful
• If school age: classroom amplification( preferably FM systems)
Recurrent AOM
Review monthly for three months
No
No
Yes
term and ease the challenges faced by the child and family, there is little evidence to suggest long-term educational benefits. Despite this, the short-term functional improvements can make a significant difference in the child’ s quality of life during patency.
LATEST INSIGHTS
Artificial intelligence and machine learning
RECENT advancements in deep
No
At least one eardrum translucent with no fluid?
Pneumatic otoscopy or tympanometry possible?
learning have significantly enhanced
Yes
Perforation
No
Yes
Is either eardrum mobile?
Management: OME and pOME: rAOMwop
Episodic bilateral OME
pOME = persistent otitis media with effusion; rAOMwop = recurrent acute otitis media without perforation. Figure 7. Algorithm for the diagnosis and management of otitis media without discharge.
No
• Observe
• Explain red flag for hearing loss and speech delay
• Continue to review
AOM without perforation
Low
• Watchful waiting
• Analgesics
• Review 2-3 days
High or low risk *?
* see 2020 OM guidelines
Low High
Yes
Dry perforation
Pneumatic otoscopy or tympanometry possible?
No
Normal eardrum( s) or unilateral OME(* observe)
Yes
Concerns about speech – language, learning, behaviour / development?
Yes
• Audiology
• Speech therapy
• Paediatrician
• ENT
• Regular review / follow-up
High or low risk *?
* see 2020 OM guidelines
High
• Amoxicillin 50mg / kg / day as tds dosing for one week
• Analgesics
• Review all children at 4-7 days
• Amoxicillin 50mg / kg / day as bd dosing for 3-6 months
• Continue with monthly review
the diagnosis, referral and management of OM. Deep-learning models— particularly those integrated into smartphone-based systems— have shown high accuracy in interpreting digital otoscopic images to detect middle ear conditions. For instance, a deep learning – enabled system using a smartphone-attached otoscope demonstrated expert-level diagnostic accuracy for identifying normal tympanic aspects and wax plugs, achieving sensitivity and specificity rates exceeding 98 %. 58
These models can assist clinicians by providing reliable diagnostic support, potentially reducing the incidence of hearing impairment and inappropriate antibiotic use.
Moreover, deep-learning approaches are being developed to predict conductive hearing loss using otoscopic images in patients with OME. These models can facilitate early detection and intervention, improving patient outcomes. 58, 59 The integration of artificial intelligence and machine learning in OM care is also being explored to tailor algorithms specifically for the management of OM, enhancing the efficiency and accuracy of diagnosis and treatment. These technological advancements hold promise for improving the overall management of OM, benefiting patients, physicians and the multidisciplinary team involved in ear healthcare. 58-60
Microbiology
In recent years, significant advancements have been made in the OM landscape, particularly in the areas of vaccine development, antibiotic stewardship and understanding the microbiology of the disease.
One of the notable developments is the progress in creating vaccines targeting the most common pathogens responsible for OM, such as S. pneumoniae, H. influenzae and M. catarrhalis. While pneumococcal and influenza vaccines are currently used to prevent OM, they primarily target specific serotypes, leaving non-vaccine serotypes and non-typeable H. influenzae as ongoing challenges. New multi-species vaccines are in preclinical trials and hold promise for broader protection against OM. 61 Other updates include a focus on antibiotic stewardship to combat the rising antimicrobial resistance among common middle ear pathogens. 61
Microbiological research has also advanced, with a deeper understanding of the pathogenesis of OM and the role of biofilms in chronic
62, 63 infections( eg, OME and CSOM). Biofilms shield bacteria from the immune system and antibiotics, explaining reduced antibiotic efficacy. Biofilms are also implicated in recurrent tonsillitis, adenoiditis, infections of implanted devices, chronic pseudomonal lung infections in cystic fibrosis and potentially bone and joint infections. 62, 63 Understanding biofilm formation and bacterial communication opens new avenues for treatment. This has led to the exploration of novel therapeutic strategies, including the use of bacteriophages and other non-antibiotic treatments to disrupt biofilms and enhance the effectiveness of existing
62, 63 antibiotics.
Autoinflation
Autoinflation is a technique used in the management of OME that involves increasing pressure in the nose to help open the Eustachian tube, thereby promoting the drainage of fluid from the middle ear. This can be achieved through methods such as blowing up a balloon through each nostril. Studies have shown that autoinflation can lead to improvements in tympanogram results and potentially reduce the duration of middle ear effusion. However, the evidence is not clear enough at this stage for routine recommendation despite it