Otitis media (OM) is the most frequent reason for which children see a doctor and can be defined as a continuum of conditions that includes acute OM (AOM) , OM with residual or persistent effusion, unresponsive OM, recurrent OM (ROM), OM with complications, and chronic OM. The pathogenic mechanisms of OM involve interactions among host characteristics, virulence factors of viral and bacterial pathogens, and environmental factors. A statistical report from the US Agency for Healthcare Research and Quality [1] examined childhood ear infections using the Medical Expenditure Panel Survey 2006 Full Year Consolidated File and showed that the expenditures for outpatient treatment and prescriptions totaled $ 2.8 billion in 2006. Annual hospital discharge rates for OM declined by 73 % as determined from the National Hospital Discharge Survey (NHDS) [2, 3].

The literature has continued to expand, increasing understanding of the worldwide burden of OM in childhood. Population-based studies confirmed reductions in OM prevalence. Although most studies concentrated on AOM or OM with effusion (OME), a few examined severe chronic suppurative OM (CSOM) , a major public health problem in developing countries and for certain indigenous populations around the world.

For most children, progression to tympanic membrane perforation and CSOM is unusual (low-risk populations). Yet in some communities, more than 4 % of the children are affected by chronic tympanic membrane perforation with chronic drainage (high-risk populations). In developing countries, where children have limited access to medical care, suppurative complications of OM are frequent with a high risk of permanent hearing loss. In developed countries, the most common morbidity of OM is conductive hearing loss due to middle ear effusion. Infants with severe and ROM and persistent middle ear effusion are at risk for problems in behavior and development of speech, language, and cognitive abilities.

Selection and spread of multidrug resistant bacterial pathogens arising from extensive use of antimicrobial agents for OM is a problem for management of all diseases due to the pathogens. The careful use of strict diagnostic criteria coupled with judicious use of antibiotic therapy will direct antibiotic treatment to only those patients likely to benefit from it. Parent stress is frequent. Evidence from a large number of randomized controlled trials can help when discussing treatment options with families. Referral to an otolaryngologist should be considered if medical therapy for recurrent AOM or chronic OME (COME) has failed or been poorly tolerated, and if chronic disease or complications are present.

OM diagnoses in children and adolescents in the USA declined by 28 % between 1997 and 2007, from 345 to 247 per 1000 children younger than 18 years [4]. The youngest children (younger than 3 years) had the highest rates of OM diagnoses, and OM diagnosis rates declined by 38 % from 1160 per 1000 children in 1997 to 840 in 2006 and 724 in 2007 [4]. From 1994 to 2009, the percentage of 2- to 3-year-old Canadian children with frequent OM (≥ 4 OM episodes) decreased from 26 % in 1994–1995 to 12.6 % in 2008–2009, a highly significant reduction ( p< 0.001). The percentage of 2- to 3-year-old children with at least one ear infection also declined significantly over this time period from 67 % in 1994–1995 to 50 % in 2008–2009 ( p< 0.001) [5] .

The introduction of pneumococcal conjugate vaccines and the guidelines encouraging primary care providers to use more stringent criteria in diagnosing AOM are probably important factors in the decline in OM incidence and prevalence. The declining rates of OM have been also associated with the increase in smoke-free homes.

In contrast to the youngest children (younger than 3 years), OM diagnosis rates among children in the USA aged 3–5 years and 6–17 years increased (275–316 and 70–107, respectively) between 2006 and 2007. Males and non-Hispanic (NH) whites had higher reported OM-related physician visit rates in all age groups [6].

All children born in Southwest British Columbia, Canada, in 1999–2000 were followed until age 3 years. In this cohort of over 50,000 births, 49 % had one or more OM diagnoses during the 3-year period of follow-up, whereas 8 % had ROM, defined as four or more physician visits over 12 months or three or more visits during a 6-month period [7].

A prospective birth cohort study in Quebec, Canada, conducted home interviews with mothers of children from age 5 months annually until 8 years of age to determine the frequency of OM and other infections. In this cohort of 1238 families, children attending large group childcare centers had an increased OM incidence compared with those in home care before the age of 2.5 years (incidence rate ratio (IRR) = 1.62; 95 % confidence interval (CI), 1.19–2.20) [8].

In 2006, the incidence rate for AOM in a study of Taiwan’s pediatric population of children younger than 12 years of age was 65 cases per 1000 children [9]. The incidence density rate (IDR) per 100 child-years for ROM during a 1-year period following the baseline AOM attack was highest among children from birth to 2 years of age, with an IDR of 41.2 cases per 100 person-years, as compared with an IDR of 38.8 for 3- to 5-year-olds and an IDR of 26.7 for 6- to 12-year-olds. Boys had slightly higher IDRs than girls (34.4 vs. 32.5). The highest recurrence rates were from birth to age 2 years (40.6 %) as compared with 3- to 5-year-olds (37.7 %) and males (34.0 %) .