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What are key findings in the history of acute otitis media?

Fever, tugging at ears, congestion/rhinorrhea, cough, waking at night, maybe language delay


What are key findings on physical exam for acute otitis media?

-First visit: TMs are bilaterally bulging, opaque, yellow/red, and poorly mobile
-Four months later: Bilateral, amber, nonmotile, retracted, opaque tympanic membranes


What is the differential diagnosis for acute otitis media?

Upper respiratory infection, sinusitis, acute otitis media, pneumonia, allergies.


What are key findings from testing with acute otitis media?

Hearing screen: mild hearing loss.


Acute otitis media (AOM):

Infection of fluid in middle ear space.


What are the most common etiologies of acute otitis media?

-Strep pneumoniae (25-50 percent)
-H. influenzae, nontypeable (15-52 percent)
-Moraxella catarrhalis (3-20 percent)
-Step pyogenes (less than 5 percent)
Viral (viruses alter mucosal lining - increasing bacterial colonization of nasopharynx - or may act as sole pathogen):


What are risk factors of acute otitis media?

Child care attendance, tobacco exposure, respiratory allergies, bottle propping, pacifier use, formula-feeding, family history of AOM, Male, lower socioeconomic status, onset of otitis in first year of life, conditions affecting craniofacial structure (cleft palate, down syndrome), genetic predisposition (native american)


What are signs and symptoms of acute otitis media?

Prior or current upper respiratory tract infection, fever, fussiness, sleeplessness, otalgia (rubbing or tubbing at ears), decreased hearing, vomiting, poor appetite.


Otitis media with effusion (OME):

Fluid in the middle ear space without signs and symptoms of acute inflammation


Otitis externa ("swimmer's ear"):

-Edematous external auditory canal
-Pain with traction on the ear lobe
-Occasionally follows perforation of the TM in AOM


Physical exam with suspected ear infection:

Start with least invasive or potentially irritating aspects of the examination first:
-Observations of the child's behavior, degree of alertness, and interactions with her parents.
-Examine heart, lungs, and abdomen
-Briefly look at the eyes for conjunctiva erythema or discharge (in case child cries with subsequent evaluation)
-Examine ears and oral cavity last


Pneumatic otoscopy:

Enables assessment of the TM including its mobility through an otoscope using an insufflation bulb.


Examination of patient's ears:

Parent participation should be attempted first. Ears may be viewed most easily if child is placed:
-On parent's lap
-On parent's chest
-On the exam table
The pinna should be pulled up and back to help see past anterior bend in the external auditory canal.
Place hand close to the head of the otoscope to guard against sudden motions.


What to look for on ear exam:

COMPT is a useful mnemonic to remember how to describe ear exam findings:
C - color (red, amber, blue, white, gray or yellow)
O - other (bubbles, scarring or perforation)
M - mobility (absent, reduced, normal or hyper mobile)
P - position (normal, retracted or bulging)
T - translucency (opaque or translucent)
A normal TM is translucent with neutral or retracted position and normal mobility.


What is the Denver developmental assessment, 2nd edition?

-Standardized developmental screening tool for children birth to 6 years of age.
-Social, fine-motor, language, and gross-motor developmental domains are assessed for potential delays
-Subsequent referral for more definitive developmental testing should follow if screening reveals a concern


What is on the differential diagnosis list for acute otitis media?

Upper respiratory tract infection (URI), Otitis media with effusion (OME), sinusitis, pneumonia, allergic rhinitis.


What is on the less likely differential diagnosis list for acute otitis media?

Gastroenteritis and urinary tract infection (UTI)


Upper respiratory tract infection (URI):

Symptoms vary depending on viral agent but may include throat irritation, sneezing, nasal congestion, cough and irritability.


Acute otitis media (AOM):

Typically develops 3-5 days after onset of URI. Symptoms include fever and otalgia (tugging on ears in a younger child).


Otitis media with effusion (OME):

Fluid (effusion) in middle ear without signs or symptoms of infection. May occur alone, secondary to URI or consequence of AOM.



Caused by superinfection of pathogenic bacteria following viral URI. Persistent URI symptoms (greater than 10 days) with day and night cough are typical in pediatric cases.



Bacterial pneumonia (much less common than viral) signaled by abrupt onset high fever, productive cough, and chest pain. May see dyspnea and tachypnea. Viral pneumonias often present with moderate fever, nonproductive cough.


Allergic rhinitis:

May be seasonal or perennial depending on type of environmental allergen. Not likely if fever also present.



Unlikely in absence of significant vomiting or diarrhea.


Urinary tract infection:

UTI is an important cause of fever in girls 18 months of age, esp. for those with no apparent source of fever by history or exam. In the absence of a definitive source of fever (eg, pneumonia or otitis media), or in the setting of persistent fever, UTI should be reconsidered.



Objective method for evaluating TM mobility.


Conventional audiometry:

Behavioral test measuring auditory thresholds in response to speech and frequency-specific stimuli presented through earphones. Used for patients 4 years old and older.


Visual reinforcement audiometry (VRA):

Behavioral test measuring response of the child to speech and frequency-specific stimuli presented through speakers in sound-proof room.
-Audiologic evaluation for kids aged 6 to 30 months, because conventional audiometry is not appropriate at very young ages.


Otoacoustic emissions (OAE):

Physiologic test measuring cochlear function in response to presentation of a stimulus. Primarily used in newborn assessments.


Cough and congestion in an infant or young child:

The US Food and Drug Administration published an advisory in January 2008 that over the counter cough and cold products not be used for infants and children under 2 years of age due to lack of demonstrated benefit and prevalence of reported adverse events, including fatal overdoses.


How often does AOM resolve spontaneously?

50-80 percent of the time!


What is nonsevere illness defined as?

Mild ear pain and temperature less than 39 deg C in previous 24 hours.


When can observation option be offered?

Only when good follow-up can be assured and antibiotics can be started should the child's condition worsen or not improve in 48 to 72 hours.


What are the complications of acute otitis media?

Mastoiditis, Meningitis, or intracranial spread.


What should you do if you are certain OR uncertain of teh diagnosis for AOM at under 6 months?

Treat with antibiotic


What should you do if certain of diagnosis from 6 mo-2 years?

Treat with antibiotic


What should you do if certain of diagnosis at greater than 2 years?

Antibiotics if severe illness. Observation if nonsevere illness.


What should you do if uncertain diagnosis between 6 mo-2 years?

Antibiotics if severe illness. Observation if nonsevere illness.


What should you do if uncertain diagnosis greater than 2 years?



What are the two best antibiotics for AOM?

Amoxicillin and Amoxicillin/clavulanata (high-dose)



-Preferred first-line therapy for AOM
-Use high-dose regimen, 80-90 mg/kg/day
-Tastes good
-Relatively good safety profile
-Fairly narrow in antibacterial activity spectrum


Amoxicillin/clavulanate (high-dose):

-Recommended by AAP and AAFP for children with higher fevers (greater than 39 C) or moderate to severe otalgia.
-Greater efficacy in treating nontypeable Hemophilus influenza, which is increasing in prevalence.


Otitis media with effusion (OME):

-Cognitive effects of long-term OME are controversial
-If mild hearing loss but no language concern, "watchful waiting" for another 3-6 months with follow-up hearing test is an option
-If persistent OME, especially with associated language delay, referral for tympanostomy tube placement would be optimal
-No strong evidence that early placement of tympanostomy tubes in otherwise healthy children with persistent OME improves developmental outcomes at 3,4, 6 or 9-11 years of age.