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Key Features

Essentials of Diagnosis

  • Moderate to severe bulging of the tympanic membrane (TM) or new otorrhea not associated with otitis externa

  • Mild bulging of the TM and less than 48 hours of otalgia (ear-holding, tugging, or rubbing in a nonverbal child) or intense erythema of the TM

  • Middle ear effusion, proven by pneumatic otoscopy or tympanometry, must be present

General Considerations

  • Bacterial or viral pathogens can be detected in up to 96% of middle ear fluid samples from patients with AOM

  • Polybacterial infections are seen in up to 55% of cases, with bacterial and viral coinfections occurring in up to 70%

  • Causative bacteria

    • Streptococcus pneumoniae and Haemophilus influenzae account for 35–40% and 30–35% of isolates, respectively

    • Moraxella catarrhalis causes up to 15–25% of cases in the United States

    • Streptococcus pyogenes is found more frequently in school-aged children than in infants

  • Most common viruses associated with AOM

    • Respiratory syncytial virus

    • Influenza virus

    • Adenovirus

    • Human metapneumovirus

    • Enteroviruses

Clinical Findings

  • Two findings are critical in establishing a diagnosis of AOM: a bulging TM and a middle ear effusion (MEE)

  • The presence of MEE is best determined by visual examination and either pneumatic otoscopy or tympanometry

  • In order to distinguish AOM from otitis media with effusion, signs and symptoms of middle ear inflammation and acute infection must be present

  • Otoscopic findings specific for AOM include

    • Bulging TM

    • Impaired visibility of ossicular landmarks

    • Yellow or white effusion (pus)

    • Opacified and inflamed eardrum

    • Squamous exudate or bullae on the eardrum

Differential Diagnosis

  • Otitis media with effusion

  • Bullous myringitis

  • Acute mastoiditis

  • Middle ear mass


  • Pneumatic otoscopy

    • Can improve diagnostic ability by 15–25%

    • The largest possible speculum should be used to provide an airtight seal and maximize the field of view

    • When the rubber bulb is squeezed, the TM should move freely with a snapping motion; if fluid is present in the middle ear space, the mobility of the TM will be absent or resemble a fluid wave

  • Tympanometry

    • Can be helpful in assessing middle ear status, particularly when pneumatic otoscopy is inconclusive or difficult to perform

    • Can reveal the presence or absence of a MEE but cannot differentiate between acutely infected fluid (AOM) and a chronic effusion (OME)

    • Measures TM compliance as well as volume of ear canal, which can help differentiate between intact and perforated TM

    • Standard 226-Hz tympanometry is not reliable in infants younger than 6 months;a high-frequency (1000 Hz) probe is used in this age group


  • Pain management

    • Mild to moderate pain should be treated with ibuprofen or acetaminophen

    • Severe pain should be treated with opioids, but careful and close observation is required to address possible respiratory depression, altered mental status, gastrointestinal upset, and constipation

    • Topical analgesics have ...

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