Does my child need antibiotics for an ear infection?

Usually not immediately. Most acute ear infections in otherwise healthy children over two settle by themselves within a few days, and the trial evidence shows antibiotics make little difference to pain in the first 24 to 48 hours — which is exactly when the child is most uncomfortable. The standard approach is a delayed or "back-up" prescription: adequate regular pain relief now, with a prescription to use only if the child is not improving after about three days or gets worse. Antibiotics are given straight away for specific groups: babies under six months; children under two with infection in both ears; any child with discharge from the ear; children who are systemically unwell; and those with immune problems, cleft palate, craniofacial abnormalities or cochlear implants.

What is glue ear and does it need treatment?

Glue ear (otitis media with effusion) is a collection of thick fluid in the middle ear without acute infection. It is extremely common in young children, usually painless, and is the commonest cause of acquired hearing loss in childhood — the child may seem inattentive, turn the television up, mishear or fall behind with speech and school. Most cases resolve on their own, so the standard approach is watchful waiting for around three months, followed by a formal hearing test and tympanometry rather than a repeat look with an otoscope alone. If hearing loss persists in both ears and is affecting speech, learning or behaviour, grommets are considered. Antibiotics, antihistamines, decongestants and steroid nasal sprays do NOT work for glue ear and should not be prescribed for it.

When is an ear infection an emergency?

When infection spreads beyond the middle ear. The most important sign is swelling and redness behind the ear with the ear pushed forward and outward, and loss of the normal crease behind the ear — this indicates mastoiditis and needs immediate hospital assessment, intravenous antibiotics, a CT scan and often surgery. Other emergency features: weakness of one side of the face (facial nerve palsy); severe vertigo with vomiting; severe headache, neck stiffness, drowsiness, confusion or seizures suggesting meningitis or intracranial abscess; and deep pain behind the eye with double vision. In addition, persistent painless foul-smelling discharge from one ear should never be dismissed as simple chronic infection — it suggests cholesteatoma, which erodes bone and requires surgery.

Why does chronic ear discharge matter so much globally?

Because chronic suppurative otitis media is a leading and largely preventable cause of permanent hearing loss, and it is heavily concentrated in low-income settings and disadvantaged populations — affecting an estimated 65 to 330 million people worldwide. The consequences extend well beyond the ear: persistent hearing loss in childhood impairs language acquisition and school performance, and translates into reduced educational attainment and lifelong economic disadvantage. The treatment is neither complex nor expensive: regular aural toilet (careful dry mopping to clear the discharge) combined with topical antibiotic drops, which achieve far higher concentrations in the middle ear than tablets. Quinolone drops such as ciprofloxacin or ofloxacin are preferred over aminoglycoside drops, because aminoglycosides can damage the inner ear when instilled through a perforation.

Can ear infections be prevented?

Several measures genuinely help. Pneumococcal conjugate vaccination reduces infections caused by the vaccine serotypes and, importantly, reduces severe complications including mastoiditis; annual influenza vaccination also modestly reduces episodes. Breastfeeding is consistently protective, more so the longer and more exclusively it continues. Avoiding exposure to tobacco smoke in the home is one of the strongest modifiable factors. Avoiding feeding a baby with a bottle while lying flat, and reducing dummy use after around six to ten months, both lower the risk. In communities with a very high burden of chronic ear disease, additional measures matter: community ear health screening to find children with persistent perforations, hearing support in schools, and reducing household crowding and indoor smoke.

How does GMJ News cover otitis media?

GMJ News covers delayed antibiotic prescribing and the specific immediate-antibiotic groups, analgesia as the primary treatment in acute otitis media, otitis media with effusion and the three-month watchful waiting pathway, grommet indications, tympanometry interpretation, chronic suppurative otitis media as a global preventable cause of hearing loss with topical quinolone therapy, mastoiditis and intracranial complications, cholesteatoma recognition, Eustachian tube dysfunction and the adult unilateral effusion red flag for nasopharyngeal carcinoma, and prevention through vaccination, breastfeeding and smoke avoidance. Directly relevant to PHIG's child health, hearing health and antimicrobial stewardship programmes.

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Otitis Media

GMJ News knowledge hub · last reviewed September 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Otitis media — inflammation of the middle ear — is one of the most common diseases of childhood, with acute otitis media (AOM) accounting for an enormous share of paediatric antibiotic prescriptions globally, and chronic suppurative otitis media (CSOM) affecting an estimated 65-330 million people worldwide, predominantly in low-income settings, where it is a leading and largely preventable cause of permanent hearing loss and consequent educational disadvantage (WHO). Most acute otitis media in otherwise healthy children over two years resolves spontaneously, and delayed or back-up antibiotic prescribing is the guideline-endorsed default — with immediate antibiotics reserved for children under six months, those under two years with bilateral disease, systemic illness, otorrhoea, immunocompromise or craniofacial abnormality — while otitis media with effusion (“glue ear”), the commonest cause of acquired childhood hearing loss, warrants three months of watchful waiting with formal hearing assessment before considering grommets, and the emergence of post-auricular swelling with a protruding pinna signals mastoiditis requiring emergency admission.

Key messages

Delayed or back-up antibiotic prescribing is the default in acute otitis media

Most acute otitis media (AOM) in otherwise healthy children over two years resolves spontaneously within a few days. NICE, AAP and most national guidelines endorse a no-antibiotic or delayed (back-up) prescription strategy with adequate analgesia as the default — the parent uses the prescription only if the child is not improving after 3 days or deteriorates. Given the enormous volume of paediatric AOM consultations, this is one of the largest antimicrobial stewardship targets in child health.

Immediate antibiotics for the specific higher-risk groups

Immediate antibiotics ARE indicated for: children under 6 months; children under 2 years with BILATERAL acute otitis media; any child with otorrhoea (discharge from a perforated drum); systemically unwell children or those with signs of serious illness; immunocompromise; craniofacial abnormality including cleft palate; cochlear implants; and children who deteriorate or fail to improve on a delayed strategy. First-line is amoxicillin (high dose in settings with pneumococcal resistance), with amoxicillin-clavulanate for treatment failure or recent antibiotic exposure.

Analgesia is the treatment that actually relieves the child

Pain is the dominant symptom and the reason families attend, yet it is routinely under-treated while attention focuses on the antibiotic decision. Regular paracetamol and ibuprofen, given at adequate dose and at fixed intervals rather than as-needed, provide the relief that matters in the first 48-72 hours — during which antibiotics make little difference regardless. Explicitly framing analgesia as "the treatment" rather than as an alternative to treatment substantially improves parental acceptance of a delayed antibiotic strategy.

Otitis media with effusion — 3 months watchful waiting, then hearing assessment

OME ("glue ear") — fluid in the middle ear without acute infection — is the commonest cause of acquired hearing loss in childhood. Most resolves spontaneously. Guidance: a period of watchful waiting of approximately 3 months with formal hearing assessment (audiometry and tympanometry) at the end, before considering intervention. Grommets (tympanostomy tubes) are indicated for persistent bilateral OME with significant hearing loss and functional impact on speech, language, learning or behaviour. Autoinflation (Otovent balloon) has modest evidence. Antibiotics, antihistamines, decongestants and intranasal steroids are NOT effective for OME and should not be used.

Chronic suppurative otitis media — a leading preventable cause of hearing loss globally

CSOM — persistent middle ear discharge through a perforated tympanic membrane for more than 2 weeks — affects an estimated 65-330 million people worldwide, overwhelmingly in low-income settings, and is a major and preventable cause of permanent hearing loss with consequent educational and economic disadvantage. WHO evidence supports aural toilet (dry mopping) plus TOPICAL antibiotics — which achieve far higher local concentrations than systemic therapy — as the mainstay. Topical quinolones (ciprofloxacin, ofloxacin) are preferred over aminoglycoside drops because of cochleotoxicity risk through a perforation.

Mastoiditis and intracranial complications — the emergency presentations

Acute mastoiditis: post-auricular swelling, redness and tenderness with the pinna pushed forward and downward, loss of the post-auricular sulcus, and systemic illness. This is an emergency requiring admission, IV antibiotics, contrast CT and often surgery (cortical mastoidectomy, myringotomy). Other complications to recognise: facial nerve palsy; labyrinthitis; petrositis (Gradenigo's syndrome — otorrhoea, deep retro-orbital pain and abducens palsy); lateral sinus thrombosis; meningitis; and intracranial abscess. Cholesteatoma — keratinising squamous epithelium in the middle ear, presenting with painless foul-smelling discharge and an attic or marginal retraction pocket — is progressive, erosive and requires surgical management.

Key statistics

Delayed Rx

back-up antibiotic prescribing is the guideline default for uncomplicated AOM in children over 2

NICE/AAP

65-330M

people worldwide affected by chronic suppurative otitis media

WHO

<2 years

with BILATERAL AOM, or any child with otorrhoea — immediate antibiotics indicated

NICE/AAP

3 months

watchful waiting with formal hearing assessment before grommets for OME

NICE/AAO-HNS

Topical

quinolone drops preferred in CSOM — higher local concentration; avoid aminoglycosides

WHO/Cochrane

Post-auricular

swelling with protruding pinna = mastoiditis = emergency admission

AAO-HNS/ENT UK

Otitis media — intervention effectiveness by condition (NICE/AAP/Cochrane)

Source: NICE/AAP/Cochrane. Analgesia and topical therapy dominate; antibiotics have no role in OME.

Glossary of key terms

Otoscopic findings
ENT/ExaminationAcute otitis media: a bulging, opaque, erythematous tympanic membrane with loss of the normal light reflex and landmarks — BULGING is the most specific single sign; erythema alone is unreliable, since a crying child's drum is often red. Otitis media with effusion: a retracted or neutral, dull, amber or grey drum, sometimes with visible fluid level or air bubbles, and reduced mobility — pneumatic otoscopy or tympanometry (type B flat trace) confirms. Perforation with otorrhoea: visible defect with discharge. Cholesteatoma: an attic or posterosuperior marginal retraction pocket filled with white keratin debris, often with granulation and foul-smelling discharge — this is the appearance that must never be dismissed as simple chronic infection.

Tympanometry
AudiologyA quick, objective measure of middle ear function that complements otoscopy and is particularly valuable in young children. Type A: normal middle ear pressure and compliance. Type B: a flat trace with normal ear canal volume — indicating middle ear effusion (glue ear); with LARGE canal volume it instead indicates a perforation or patent grommet. Type C: significantly negative middle ear pressure — Eustachian tube dysfunction, often preceding or following effusion. Tympanometry does not measure hearing and must be paired with age-appropriate audiometry — visual reinforcement audiometry, play audiometry or pure tone audiometry depending on developmental age — before decisions about grommets are made.

Grommets (tympanostomy tubes)
ENT surgerySmall ventilation tubes inserted through the tympanic membrane to drain effusion and equalise middle ear pressure, typically extruding spontaneously after 6-12 months. Indications: persistent bilateral OME (usually 3+ months) with hearing loss and demonstrable functional impact on speech, language, learning or behaviour; recurrent AOM (commonly 3 episodes in 6 months or 4 in 12); OME in a child with additional risk such as Down syndrome, cleft palate, permanent hearing loss in the other ear, or visual impairment, where the threshold is lower. Effects on hearing are immediate but the benefit narrows over time as untreated effusions also resolve. Practical points: routine water precautions are no longer required for most children; otorrhoea through a grommet is treated with topical quinolone drops rather than oral antibiotics; and long-term risks include tympanosclerosis and persistent perforation in a small minority.

Cholesteatoma
ENTKeratinising stratified squamous epithelium trapped within the middle ear or mastoid, forming an expanding sac of keratin debris that erodes bone through pressure and enzymatic activity. Acquired cholesteatoma usually arises from a retraction pocket driven by chronic Eustachian tube dysfunction; congenital cholesteatoma presents as a white mass behind an intact drum in a young child. Clinical hallmark: persistent, painless, foul-smelling otorrhoea that does not resolve, with an attic or posterosuperior retraction pocket. It is progressive and will not resolve medically. Untreated complications: conductive then sensorineural hearing loss from ossicular erosion, facial nerve palsy, labyrinthine fistula with vertigo, mastoiditis, meningitis and intracranial abscess. Management is surgical — tympanomastoid surgery with long-term surveillance or planned second-look for residual disease.

Eustachian tube dysfunction
ENT/PhysiologyThe underlying mechanism in most middle ear disease. The Eustachian tube ventilates the middle ear and equalises pressure; when it fails, negative middle ear pressure develops, causing retraction, transudation of fluid, and ultimately effusion, retraction pockets and cholesteatoma. Children are predisposed because their Eustachian tube is shorter, more horizontal and more compliant — which is why middle ear disease is fundamentally a paediatric problem that improves with craniofacial growth. Risk factors: upper respiratory infection; allergic rhinitis; adenoid hypertrophy; cleft palate and craniofacial syndromes; Down syndrome; passive smoking; and childcare attendance. IMPORTANT red flag: unilateral OME in an ADULT — particularly of South-East Asian or southern Chinese origin, or with neck lymphadenopathy or epistaxis — requires nasopharyngoscopy to exclude nasopharyngeal carcinoma obstructing the Eustachian tube.

Prevention of otitis media
Public health/PaediatricsSeveral measures have good evidence. Pneumococcal conjugate vaccination reduces AOM caused by vaccine serotypes and, importantly, reduces complicated disease and mastoiditis; influenza vaccination modestly reduces AOM episodes. Breastfeeding is consistently protective, with effect increasing with duration and exclusivity. Avoidance of passive smoking is one of the strongest modifiable factors. Avoiding supine bottle feeding, and reducing dummy (pacifier) use beyond around 6-10 months, both reduce risk. In high-burden settings — including remote Indigenous populations where CSOM prevalence can exceed the WHO threshold defining a massive public health problem — additional measures matter: early identification through community ear health screening, treatment of persistent perforation, hearing support in schools, and reduction of household crowding and smoke exposure.

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Otitis Media

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