Questionnaire/history: Acute onset of earache? Holding, tugging, or rubbing of the ear? Non-specific symptoms (eg fever, crying, poor feeding, restlessness, behavioural changes, cough, or rhinorrhoea)? Past medical history? Current medication? Drug allergies? Examination: Red, yellow, or cloudy tympanic membrane? Moderate to severe bulging of the tympanic membrane, with loss of normal landmarks and an air-fluid level behind the tympanic membrane (indicating a middle ear effusion)? Perforation of the tympanic membrane? Discharge in the external auditory canal? (In children younger than 6 months of age (and particularly younger than 3 months of age), diagnosis can be difficult because the tympanic membrane may not be visible; it often lies in an oblique position and the ear canal is small and tends to collapse.) Management Advised: - Usual course of acute otitis media is about 3 days, but can be up to 1 week - Regular doses of paracetamol or ibuprofen for pain - Advised antibiotic not being needed OR - Back-up prescription for amoxicillin for 5 days with advice about an antibiotic not being needed immediately and to use the back-up prescription if symptoms do not start to improve within 3 days or worsen significantly or rapidly at any time OR - Amoxicillin for 5-7 days (eg if otorrhoea or those aged < 2 years with bilateral infection) To seek medical advice if new or worsening symptoms, no improvement after 3 days or ongoing symptoms Resource(s): NICE CKS: Otitis media Information for patient/carer(s): Patient: Ear infection (Otitis Media)