• 
  

  Distinguish between acute otitis media (AOM) and otitis media with effusion (OME), both of which present with a middle ear effusion.

  
  
• 
  

  Clinical findings most suggestive of AOM are a bulging tympanic membrane (TM) with a purulent effusion, whereas the TM in OME has a clear effusion with a normal or retracted position.

  
  
• 
  

  Erythema alone is a poor predictor of AOM and must be combined with other TM characteristics to make a diagnosis.

  
  
• 
  

  Antibiotic treatment may be indicated for some episodes of AOM, but is not indicated for OME.

  
  
• 
  

  Assess the patient for possible complications of AOM.

Otitis media refers to the presence of inflammation or infection in the middle ear space. A middle ear effusion without infection is called otitis media with effusion (OME) or serous otitis. Infection of fluid in the middle ear is called acute otitis media (AOM). Diagnosis of AOM should be based on the acute onset of signs or symptoms of middle ear inflammation (fever, ear pain, distinct erythema of the tympanic membrane) in conjunction with a middle ear effusion seen on physical exam.

Ear disease is common in children, with 90% of children having at least 1 episode of a middle ear effusion and two thirds with at least 1 episode of AOM by school age. The peak incidence of AOM occurs between 6 and 24 months of age.

Episodes of AOM are often preceded by a viral upper respiratory tract infection (URI). The eustachian tube in children is shorter and more horizontal than in adults. Eustachian tube dysfunction associated with a URI can lead to a middle ear effusion (OME). Bacterial pathogens in the nasopharynx ascend via the eustachian tube, leading to infection of the fluid in the middle ear (AOM).

AOM is caused by bacteria in 50–80% of cases, most commonly Streptococcus pneumoniae or nontypable Haemophilus influenzae and less commonly Moraxella catarrhalis. Purulent otorrhea may be caused by Staphylococcus aureus or Pseudomonas aeruginosa as well. Common complications of AOM are persistent middle ear effusion, tympanic membrane perforation, and tympanosclerosis. Other complications of AOM include cholesteatoma, hearing loss, tinnitus, balance problems, and facial nerve injury. Intracranial complications are rare and include mastoiditis, intracranial abscess, meningitis, and venous sinus thrombosis.

History

Children with AOM usually present with acute onset of signs and symptoms of inflammation from AOM, such as fever and ear pain. This is often preceded by URI symptoms. Many symptoms associated with AOM, such as fever, irritability, restless sleep, and crying, are neither sensitive nor specific for AOM, and may be present in children with a URI with or without AOM. The presence of ear pain increases the relative risk of a patient having AOM. Purulent drainage from the ear may be present with AOM with tympanic membrane perforation or with otitis externa. Previous episodes of AOM, including timing of most recent infection and antibiotic use may influence choice of therapy. Persistent fever and headache may be signs of intracranial complications of AOM.

Physical Examination

Fever, though nonspecific, is present in 50% of cases of AOM. Careful examination of the head and neck, including the oropharynx, teeth, jaw, and lymph nodes, should be done to search for other causes of pain that may be referred to the ear. Inspection of the pinna, tragus, and external auditory canal, as well as palpation of the tragus, should be performed. Pain with manipulation of the pinna or tragus, in conjunction with purulent otorrhea and inflammation of the external auditory canal, suggests otitis externa. The mastoid process should be examined for swelling, erythema, and tenderness, signs of mastoiditis. With mastoiditis, the pinna may also be displaced anteriorly.