Acute symptoms are required for the diagnosis of acute otitis media (AOM) and they guide the management together with the laterality of AOM. However, symptoms are variable in young children and not diagnostic with AOM. 

We investigated ear pain with parentally used pain scales, clinical characteristics of bilateral and unilateral AOM, symptoms and nasopharyngeal microbes and the need for follow-up of children with AOM initially managed without antimicrobials. We included children (6-35 months) with respiratory tract infection (RTI) whose parents suspected AOM. 

In children with RTI, either with or without AOM, ear pain was assessed as moderate/severe in 80-90% with parentally used pain scales, compared with 56-65% with parental interview. In children with bilateral vs. unilateral AOM, fever occurred in 54% vs. 36% and moderate/severe bulging of tympanic membrane in 63% vs. 40%. In children with the suspicion of AOM, respiratory symptoms were associated with the nasopharyngeal colonization of Moraxella catarrhalis in the presence of viruses and fever was associated with respiratory viruses. Of the children with AOM initially managed without antimicrobials who had symptomatic improvement, the otoscopic signs worsened in 3%. 

Majority of children with RTI suffer from moderate/severe ear pain or distress, when assessed by parents, regardless of AOM. Without pain scales, parents may underestimate children’s pain. Clinically, bilateral AOM is only slightly more severe illness than unilateral AOM. Symptoms are associated with nasopharyngeal microbes. For children with AOM who are initially managed without antimicrobials and who are symptomatically improving, close follow-up may be unnecessary.