The 2013 Guidelines [6] for the treatment of AOM define “severe AOM” as AOM with the presence of moderate to severe otalgia or fever equal or higher than 39.0 °C. The definition for “non-severe” AOM is AOM with the presence of mild otalgia and temperature below 39.0 °C. The guidelines recommend clinicians prescribe antibiotic therapy for bilateral AOM in children younger than 2 years old, children 6 months and older with evidence of severe AOM (bilateral or unilateral), and to all patients with otorrhea. The recommendations state for patients 6 months to 2 years with non-severe unilateral AOM, or patients older than 2 years with bilateral non-severe AOM without otorrhea, clinicians should prescribe antibiotic therapy or offer observation with close follow-up (48–72 h) based on joint decision-making with the parents and caregivers.

A study from the Netherlands [13] reported 4860 consecutive Dutch patients (< 2 years old) with AOM who were treated with nose drops and analgesic alone. They report 90 % recovered within the first few days and concluded that AOM in children can be treated symptomatically without antibiotic therapy for the first 3–4 days; of note, despite the lack of antibiotic therapy, this study had only one new case of mastoiditis and no cases of bacterial meningitis.

Highlighting the difficulty of clinically implementing new guidelines, three studies looked US physicians treatment of AOM after guidelines [6] were released and found the management of AOM without antibiotics had not increased [14] and the variability of prescribed antibiotics for AOM actually increased from before the published guideline recommendations [15]. Chu et al. looked retrospectively at 207 patients treated for uncomplicated AOM and found overall adherence to the guidelines was only 8.2 % [16].

The decision to proceed with the WW method is multifactorial and does require a trusted physician–parent/patient relationship. McCormick et al. [12] describe five key factors needed in implementing a WW strategy: a method to classify AOM severity, parent education regarding the risks and benefits of treatment, management of AOM symptoms, access to follow-up care, and use of an effective antibiotic regimen if needed. When considering the WW method, it is important to take into consideration the patient’s age, degree of certainty about the diagnosis, the severity of the illness, as well as parental concerns/level of comfort.

Chronic suppurative otitis media (CSOM) is defined as a chronic infection of the middle ear in which a non-intact tympanic membrane and otorrhea are present [17]. There is no consensus on the duration of otorrhea required to make the diagnosis, although the World Health Organization uses a definition where the otorrhea must be present for “at least 2 weeks,” [18] while others define “chronic” as a persistence of symptoms for 6 weeks or greater [19–21]. CSOM remains one of the most common chronic infections of childhood in many developing countries [22]. Sequel a of CSOM can include chronic hearing loss and subsequent speech/language delay, as well as the potential danger of life-threatening suppurative complications (i.e., mastoiditis, meningitis, and epidural abscess).

An Optimal treatment strategy has not yet been established but topical treatment with otic antibiotic drops, combined with frequent and aggressive aural toilet have been the mainstay [21, 23, 24]. The effectiveness of ototopical drops was evaluated in a Cochrane Review [23] which concluded that antibiotic or antiseptic eardrops accompanied by aural toilet was the most effective treatment; this treatment regimen was more effective than systemic antibiotics , and aural toilet alone. Combined topical and systemic antibiotics were not more effective than treatment with topical antibiotics alone in terms of otorrhea resolution. Several studies have supported quinolone eardrops to be more effective than non-quinolones [18, 23, 25, 26]. When granulation tissue is present, adding a steroid to the ototopical antibiotics is recommended [21, 24].

Consensus is lacking regarding the utility of systemic antibiotics for this disease process. An expert panel by the American Academy of Otolaryngology-Head and Neck Surgery concluded in the absence of systemic infections or serious underlying disease, topical antibiotics alone should be considered first-line treatment [24]. Evidence is also lacking regarding choice of antibiotic and duration of therapy; both broad-spectrum antibiotics as well as culture-directed therapy have been advocated as initial oral therapy for CSOM [22]. Finally, in children with evidence of complications of CSOM may require CT scan and initiation of intravenous antibiotics [19, 20, 25].

OME is the most common cause of childhood hearing loss [27]. Several studies have looked at whether there is benefit of medical therapy for persistent OME. Although some studies report a statistically significant benefit when using specific medications [28, 29], these are short-term benefits and relatively small in overall magnitude. In a meta-analysis by Williams et al. [28], they found six patients needed to be treated to improve the short-term outcome in one patient. The authors’ question the utility of this short-term benefit given the major goal of treatment of OME is the prevention of language or developmental delays second to hearing loss, which occur over a long period of time. This study also found no significant difference between placebo and antibiotics in eight studies of long-term outcomes of OME [28]. The 2004 clinical guidelines [7] report the risk of adverse events which may occur with all medical therapies, outweigh the small benefit they may provide, and do not recommend antibiotics. A Cochrane Review published in 2012 [30] does not support the routine use of antibiotics for children with OME. In the review, the largest clinical improvement was found in children treated with continuous antibiotics for 4 weeks to 3 months. The authors’ conclude that the modest benefit of antibiotic therapy observed must be balanced against the risks of adverse effects of antibiotics and the emergence of bacterial resistance.