The following summarizes the diagnostic criteria for AOM:

• Identify the presence of one or more of the following:
  • Moderate to severe bulging of the tympanic membrane
  • Mild bulging of the tympanic membrane and recent (<48 hours) onset of ear pain* (otalgia)
  • Intense erythema (redness) of the tympanic membrane
  • New onset of otorrhea not due to acute otitis externa
  **Otalgia may present in a nonverbal child as holding, tugging, and rubbing of the ear.

• Assess the laterality and severity of symptoms to determine treatment options.

•  Treat in these cases:

• Severe AOM (fever ≥39°C, moderate to severe otalgia, or otalgia for at least 48 hours)
• Bilateral, nonsevere* AOM in young children 6–23 months of age
• Otorrhea in the setting of AOM

•  Initial observation (watchful waiting) for 48–72 hours is an option in these cases:

• Nonsevere*, unilateral AOM in young children 6–23 months of age
• Nonsevere*, unilateral or bilateral, AOM in older children ≥24 months of age

*Nonsevere AOM = mild otalgia less than 48 hours and fever less than 39°C (102.2°F)