agents include ibuprofen, paracetamol (acetaminophen), and opiates. evidence for the combination over single agents is lacking. topical agents shown to be effective include antipyrine and benzocaine ear drops. decongestants and antihistamines, either nasal or oral, are not recommended due to the lack of benefit and concerns regarding side effects. half of cases of ear pain in children resolve without treatment in three days and 90% resolve in seven or eight days. the use of steroids is not supported by the evidence for acute otitis media. antibiotics it is important to weigh the benefits and harms before using antibiotics for acute otitis media. as over 82% of acute episodes settle without treatment, about 20 children must be treated to prevent one case of ear pain, 33 children to prevent one perforation, and 11 children to prevent one opposite-side ear infection. for every 14 children treated with antibiotics, one child has an episode of either vomiting, diarrhea or a rash. if pain is present, pain medications may be used. for people requiring surgery to treat otitis media with effusion, preventative antibiotics may not help reduce the risk of post-surgical complications. for bilateral acute otitis media in infants younger than 24 months of age, there is evidence that the benefits of antibiotics outweigh the harms. a 2015 cochrane review concluded that watchful waiting is the preferred approach for children over six months with non severe acute otitis media. summary outcome findings in words findings in numbers quality of evidence pain pain at 24 hoursantibiotics causes little or no reduction to the chance of experiencing the outcome when compared with placebo for acute otitis media in children. data are based on high quality evidence. rr 0.89 (0.78 to 1.01)high pain at 2 to 3 daysantibiotics slightly reduces the chance of experiencing the outcome when compared with placebo for acute otitis media in children. data are based on high quality evidence. rr 0.70 (0.57 to 0.86)high pain at 4 to 7 daysantibiotics slightly reduces the chance of experiencing the outcome when compared with placebo for acute otitis media in children. data are based on high quality evidence. rr 0.76 (0.63 to 0.91)high pain at 10 to 12 daysantibiotics probably reduces the chance of experiencing the outcome when compared with placebo for acute otitis media in children. data are based on moderate quality evidence. rr 0.33 (0.17 to 0.66)moderate abnormal tympanometry 2 to 4 weeksantibiotics slightly reduces the chance of experiencing the outcome when compared with placebo for acute otitis media in children. data are based on high quality evidence. rr 0.82 (0.74 to 0.90)high 3 monthsantibiotics causes little or no reduction to the chance of experiencing the outcome when compared with placebo for acute otitis media in children. data are based on high quality evidence. rr 0.97 (0.76 to 1.24)high vomiting diarrhoea or rashantibiotics slightly increases the chance of experiencing the outcome when compared with placebo for acute otitis media in children. data are based on high quality evidence. rr 1.38 (1.19 to 1.59)high most children older than 6 months of age who have acute otitis media do not benefit from treatment with antibiotics. if antibiotics are used, a narrow-spectrum antibiotic like amoxicillin is generally recommended, as broad-spectrum antibiotics may be associated with more adverse events. if there is resistance or use of amoxicillin in the last 30 days then amoxicillin-clavulanate or another penicillin derivative plus beta lactamase inhibitor is recommended. taking amoxicillin once a day may be as effective as twice or three times a day. while less than 7 days of antibiotics have fewer side effects, more than seven days appear to be more effective. if there is no improvement after 2–3 days of treatment a change in therapy may be considered. azithromycin appears to have less side effects than either high dose amoxicillin or amoxicillin/clavulanate. tympanostomy tube tympanostomy tubes (also called "grommets") are recommended with three or more episodes of acute otitis media in 6 months or four or more in a year, with at least one episode or more attacks in the preceding 6 months. there is tentative evidence that children with recurrent acute otitis media (aom) who receive tubes have a modest improvement in the number of further aom episodes (around one fewer episode at six months and less of an improvement at 12 months following the tubes being inserted). evidence does not support an effect on long-term hearing or language development. a common complication of having a tympanostomy tube is otorrhea, which is a discharge from the ear. the risk of persistent tympanic membrane perforation after children have grommets inserted may be low. it is still uncertain whether or not grommets are more effective than a course of antibiotics. oral antibiotics should not be used to treat uncomplicated acute tympanostomy tube otorrhea. they are not sufficient for the bacteria that cause this condition and have side effects including increased risk of opportunistic infection. in contrast, topical antibiotic eardrops are useful. otitis media with effusion the decision to treat is usually made after a combination of physical exam and laboratory diagnosis, with additional testing including audiometry, tympanogram, temporal bone ct and mri. decongestants, glucocorticoids, and topical antibiotics are generally not effective as treatment for non-infectious, or serous, causes of mastoid effusion. moreover, it is recommended against using antihistamines and decongestants in children with ome. in less severe cases or those without significant hearing impairment, the effusion can resolve spontaneously or with more conservative measures such as autoinflation. in more severe cases, tympanostomy tubes can be inserted, possibly with adjuvant adenoidectomy as it shows a significant benefit as far as the resolution of middle ear effusion in children with ome is concerned. chronic suppurative otitis media topical antibiotics are of uncertain benefit as of 2020. some evidence suggests that topical antibiotics may be useful either alone or with antibiotics by mouth. antiseptics are of unclear effect. topical antibiotics (quinolones) are probably better at resolving ear discharge than antiseptics. alternative medicine complementary and alternative medicine is not recommended for otitis media with effusion because there is no evidence of benefit. homeopathic treatments have not been proven to be effective for acute otitis media in a study with children. an osteopathic manipulation technique called the galbreath technique was evaluated in one randomized controlled clinical trial; one reviewer concluded that it was promising, but a 2010 evidence report found the evidence inconclusive. outcomes disability-adjusted life year for otitis media per 100,000 inhabitants in 2004. no data < 10 10–14 14–18 18–22 22–26 26–30 30–34 34–38 38–42 42–46 46–50 > 50 deaths from otitis media per million persons in 2012 0 1 2–4 complications of acute otitis media consists of perforation of the ear drum, infection of the mastoid space behind the ear (mastoiditis), and more rarely intracranial complications can occur, such as bacterial meningitis, brain abscess, or dural sinus thrombosis. it is estimated that each year 21,000 people die due to complications of otitis media. membrane rupture in severe or untreated cases, the tympanic membrane may perforate, allowing the pus in the middle-ear space to drain into the ear canal. if there is enough, this drainage may be obvious. even though the perforation of the tympanic membrane suggests a highly painful and traumatic process, it is almost always associated with a dramatic relief of pressure and pain. in a simple case of acute otitis media in an otherwise healthy person, the body's defenses are likely to resolve the infection and the ear drum nearly always heals. an option for severe acute otitis media in which analgesics are not controlling ear pain is to perform a tympanocentesis, i.e., needle aspiration through the tympanic membrane to relieve the ear pain and to identify the causative organism(s). hearing loss children with recurrent episodes of acute otitis media and those with otitis media with effusion or chronic suppurative otitis media have higher risks of developing conductive and sensorineural hearing loss. globally approximately 141 million people have mild hearing loss due to otitis media (2.1% of the population). this is more common in males (2.3%) than females (1.8%). this hearing loss is mainly due to fluid in the middle ear or rupture of the tympanic membrane. prolonged duration of otitis media is associated with ossicular complications and, together with persistent tympanic membrane perforation, contributes to the severity of the disease and hearing loss. when a cholesteatoma or granulation tissue is present in the middle ear, the degree of hearing loss and ossicular destruction is even greater. periods of conductive hearing loss from otitis media may have a detrimental effect on speech development in children. some studies have linked otitis media to learning problems, attention disorders, and problems with social adaptation. furthermore, it has been demonstrated that individuals with otitis media have more depression/anxiety-related disorders compared to individuals with normal hearing. once the infections resolve and hearing thresholds return to normal, childhood otitis media may still cause minor and irreversible damage to the middle ear and cochlea. more research on the importance of screening all children under 4 years old for otitis media with effusion needs to be performed. epidemiology acute otitis media is very common in childhood. it is the most common condition for which medical care is provided in children under five years of age in the us. acute otitis media affects 11% of people each year (709 million cases) with half occurring in those below five years. chronic suppurative otitis media affects about 5% or 31 million of these cases with 22.6% of cases occurring annually under the age of five years. otitis media resulted in 2,400 deaths in 2013—down from 4,900 deaths in 1990. etymology the term otitis media is composed of otitis, ancient greek for "inflammation of the ear", and media, latin for "middle".