The management of recurrent acute otitis media and serous otitis media is both challenging and controversial. The efficacy of antimicrobial prophylaxis of children at high risk for recurrent acute otitis media is established, but the indications for such therapy are controversial. Tympanostomy tube insertion also decreases the frequency of recurrent otitis media. High-risk children can be successfully managed with chemoprophylaxis from autumn through to spring. If this fails, then tympanostomy tube insertion should be considered. Serous otitis media that follows acute otitis media resolves spontaneously in more than 90% of cases. Serous otitis media of unknown onset also has a strong tendency to resolve without treatment. Antihistamines and decongestants, although popular, have no significant effect on the course of serous otitis media. Antimicrobial therapy has a modest effect on the resolution of serous otitis media. Tympanostomy tubes usually improve the conductive hearing loss associated with serous otitis media and should be used when bilateral serous otitis media fails to resolve spontaneously. If repeated tympanostomy tube insertion fails, then adenoidectomy should be considered. With the course of management outlined, most children will have a successful outcome with conservative therapy and the need for surgery will be minimised.