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Clinical Summary

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Diagnosis of acute otitis media (AOM) requires (1) a history of acute onset of signs/symptoms, (2) presence of middle-ear effusion, and (3) signs/symptoms of middle-ear inflammation. Accurate diagnosis can be challenging yet is essential for proper management. AOM is considered highly likely if distinct bulging of the tympanic membrane (TM) or acute purulent otorrhea (not caused by acute otitis externa) are seen. AOM is considered possible with mild bulging of the TM with recent onset of otalgia plus opacification, distinct erythema, or reduced mobility (on pneumatic otoscopy). AOM is considered unlikely with findings of middle-ear effusion without bulging or distinct erythema of the TM (eg, otitis media with effusion). Otalgia or other nonspecific symptoms (eg, fever, irritability) without middle-ear effusion or a bulging TM are not consistent with the diagnosis of AOM.

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It can be difficult to fully visualize the TM to make the diagnosis; obstructing cerumen can be gently removed with suction or curettage, and AOM should not be diagnosed empirically when the TM is poorly visualized. Instead, refer the patient to otolaryngology for cerumen removal and additional assessment.

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Emergency Department Treatment and Disposition

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Adequate pain relief is an essential part of management, especially in the first 24 hours after diagnosis. Acetaminophen or ibuprofen is recommended; narcotics are rarely necessary and should be avoided. Antibiotics do not reduce pain associated with AOM in the first 24 to 48 hours and should not be used for this purpose. Topical analgesic drops typically containing benzocaine provide mild pain relief for 20 to 60 minutes after administration and may be useful between administration of oral analgesics and onset of pain relief. Topical analgesic drops should not be used if the TM is perforated or a tympanostomy tube is in place.

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Choose the antibiotic based on likely pathogens and resistance patterns in the community. Most AOM is caused by Streptococcus pneumoniae (20%–40% penicillin resistant), Haemophilus influenzae (30% β-lactamase producing), or Moraxella catarrhalis (100% β-lactamase producing). Recommended antibiotics include amoxicillin (with or without clavulanate), cefuroxime, cefdinir, and cefpodoxime. Children who are allergic to penicillin or unable to tolerate cephalosporins can receive clarithromycin or azithromycin. Duration of therapy is generally 7 to 10 days, though children aged >2 years may respond to short-course therapy of 5 days. Intramuscular ceftriaxone is appropriate as single-dose treatment for children who cannot tolerate oral antibiotic (eg, severe vomiting) or as a series of 3 consecutive daily injections for children with refractory AOM unresponsive to oral antibiotics.

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Figure 9.1 ▪ Normal Tympanic Membrane.
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Normal tympanic membrane in a neutral position without middle-ear effusion. (Photo contributor: Richard Rosenfeld, MD.)

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Initiate antibiotic therapy immediately in infants <6 months of age, in patients with AOM accompanied by otorrhea or bilateral AOM in children <2 years of age. If the above criteria are not met, there is a role for delayed antibiotic therapy in which a safety-net antibiotic prescription (SNAP) is given with an advice to fill the prescription (and begin therapy) only if the child does not improve within 72 hours ...

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