Aim: To compare the effectiveness of antibiotic versus non-antibiotic management in treating acute otitis media (AOM) in children, focusing on symptom resolution, treatment failure, need for rescue therapy, and adverse events. Materials and Methods: This prospective, comparative, randomized clinical trial was conducted at a tertiary care hospital and included 120 pediatric patients aged 6 months to 12 years diagnosed with AOM. Patients were randomly assigned to two groups:Antibiotic Group (AG) (n=60) received amoxicillin-clavulanate or azithromycin for 7–10 days.Non-Antibiotic Group (NAG) (n=60) received symptomatic treatment with analgesics, nasal decongestants, and observation for 48–72 hours.Primary outcomes included symptom resolution at 48 hours, 7 days, and 14 days, while secondary outcomes included treatment failure, need for rescue antibiotics, and adverse events. Data were analyzed using chi-square and t-tests, with a significance level of p<0.05. Results: Baseline characteristics were similar between both groups (p>0.05). At 48 hours, symptom resolution was higher in AG (58.33%) compared to NAG (41.67%) (p=0.04). By 14 days, resolution rates were 96.67% in AG vs. 91.67% in NAG (p=0.37), suggesting similar long-term recovery. Treatment failure was significantly higher in NAG (20.00%) than in AG (8.33%) (p=0.03). The need for rescue antibiotics was observed in 16.67% of NAG patients, whereas none in AG required additional antibiotics (p<0.01). Adverse events, particularly diarrhea, were more frequent in AG (13.33%) than in NAG (5.00%) (p=0.12), though not statistically significant. Conclusion: While antibiotics may accelerate early symptom relief, long-term outcomes remain similar between antibiotic and non-antibiotic management. Watchful waiting is a safe and effective alternative for many children with mild to moderate AOM, reducing unnecessary antibiotic exposure and potential adverse effects. However, select cases with severe symptoms or high risk of complications may still benefit from antibiotic therapy.