The term otitis media (OM) has been used to describe multiple disorders of the middle ear, including acute otitis media (AOM), otitis media with effusion (OME), chronic OME, and the umbrella designation including all of these terms. This chapter uses the term otitis media in its historic usage as an umbrella term including AOM and OME, and uses the terms AOM and OME as specific disease processes as defined below. The purpose of the chapter is to describe the contemporary approach to diagnosis and management of AOM and to discuss OME as it relates to AOM.
As few as 50% of pediatricians in the United States are aware of recent guidelines for diagnosis and management of AOM. Only 28% of those aware of these guidelines changed their practice as a result.1 University-affiliated pediatricians’ diagnoses of AOM complied with Centers for Disease Control and Prevention diagnostic criteria only 38% of the time during the winter of 1999–2000.2 Additionally, tympanometry as an adjunct to otoscopy did not improve diagnostic accuracy or decrease antibiotic usage.3 In Finland, implementation of a national guideline for OM resulted in health benefits and lower direct costs.4 One conclusion from the Finnish data is that adherence to such guidelines may improve care and reduce use of antibiotics.
OME is usually the result of AOM. Therefore, AOM and OME are pathologic processes along the same disease continuum. This relationship has resulted in diagnostic uncertainty and variations in the definition of AOM over time. However, establishing a uniform and appropriate definition is of utmost importance if AOM is to be diagnosed and managed appropriately. The most important distinction is that OME is not treated with antibiotics, whereas AOM may be treated with antibiotics. This difference exemplifies the need for uniform and appropriate definitions, diagnostic criteria, and management schema for AOM and OME.5,6
With the above caveat in mind, the American Academy of Pediatrics Subcommittee on Management of AOM and the Agency for Healthcare Research and Quality has established a definition of AOM.7–9 This definition requires the presence of three equally important elements8:
Acute onset (<48 hours) of signs and symptoms, and
Middle-ear effusion (MEE), and
Signs and symptoms of middle-ear inflammation.
Methods and criteria for the diagnosis of AOM pertaining to each of these diagnostic elements are included in the following sections and in Table 28–1.
Table 28–1. Diagnostic Elements, Method, and Criteria for Diagnosing AOM7 |Favorite Table|Download (.pdf)
Table 28–1. Diagnostic Elements, Method, and Criteria for Diagnosing AOM7
History of illness
Pneumatic otoscopy or
Bulging of the TM
Limited TM mobility
Air fluid level behind TM
Middle ear inflammation
At least one: fever, otalgia, irritability in infant, red TM not because of crying or fever42