AUTHOR INFORMATION

Section 1 of 12

Authored by Kathy A Cook, MD, Consulting Staff, Department of Emergency Medicine, Providence Memorial Hospital

Coauthored by Matthew Walsh, MD, Chair, Associate Professor, Department of Emergency Medicine, Texas Tech University Health Sciences Center

Kathy A Cook, MD, is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Texas Medical Association

Edited by Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Medical Director, Saint Barnabas Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center, Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Pamela Dyne, MD, Program Director, Associate Professor, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine

Author's Email:	Kathy A Cook, MD
Editor's Email:	Jerry Balentine, DO

eMedicine Journal, May 23 2005, VOLUME 6, Number 5

INTRODUCTION

Section 2 of 12

Background: The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) define acute otitis media as an infection of the middle ear with acute onset, presence of middle ear effusion (MEE), and signs of middle ear inflammation. Acute otitis media most commonly occurs in children and is the most frequent specific diagnosis in children who are febrile. Physicians, including those in the ED, often overdiagnose acute otitis media.

Bulging of the tympanic membrane is the highest predictive value when evaluating the presence of MEE. Other findings that indicate the presence of MEE include limited mobility of the tympanic membrane with pneumatic otoscopy and fluid visualized behind the tympanic membrane or in the ear canal (with perforation).

Distinguishing between acute otitis media and otitis media with effusion (OME) is important. OME is more common than acute otitis media. When OME is mistaken for acute otitis media, antibiotics may be prescribed unnecessarily. OME is fluid in the middle ear without signs or symptoms of infection. OME is usually caused when the eustachian tube is blocked and fluid becomes trapped in the middle ear. Signs and symptoms of acute otitis media occur when fluid in the middle ear becomes infected.

Recurrent otitis media is defined as 3 episodes of acute otitis media within 6 months or 4 or more episodes within 1 year.

Pathophysiology: Acute otitis media usually arises as a complication of a preceding viral upper respiratory infection (URI). The secretions and inflammation cause a relative occlusion of the eustachian tubes. Normally, the middle ear mucosa absorbs air in the middle ear. If air is not replaced because of relative obstruction of the eustachian tube, a negative pressure is generated and causes a serous effusion. This effusion of the middle ear provides a fertile media for microbial growth, and, with the URI, introduction of upper airway viruses and/or bacteria into the middle ear may occur. If growth is rapid, the patient will have a middle ear infection. If the infection and the resultant inflammatory reaction persist, perforation of the tympanic membrane or extension into the adjacent mastoid air cells may be present.

Frequency:

• In the US: Otitis media is common, with 50% of children having an episode before their first birthday and 80% of children having one by their third birthday. An estimated 3-4 billion dollars are spent each year on care of patients with acute otitis media and related complications.

Mortality/Morbidity:

• Mortality is rare in countries where treatment for complications is available, and it is not frequent in countries where treatment is not available.

• Morbidity may be significant for infants in whom persistent MEE develops. MEE leads to hearing deficits and speech delay. Most spontaneous perforations eventually heal, but some persist. Frequent recurrences of acute otitis media are relatively common.

• Otitis is not considered a major source of bacteremia or meningeal seeding, but local brain abscess has been documented, demonstrating that it is possible for acute otitis media to extend.

Race: Otitis media is more frequent in certain racial groups (eg, Inuit and American Indians) than in others.

• Other factors in the environment (eg, crowding, daycare setting, nutrition) may be more important than race, but they have not been fully delineated.

• Otitis media is less common in groups with high rates of breastfeeding than in groups with low rates of breastfeeding.

Sex: Boys are affected more commonly than girls, but no specific causative factors have been found. Male sex is a minor determinant of infection.

Age:

• Ear infection occurs in all age groups, but it is considerably more common in children, particularly those aged 6 months to 3 years, than in adults. This age distribution is presumably due to immunologic factors (eg, lack of pneumococcal antibodies) and anatomic factors (eg, a low angle of the eustachian tube with relation to the nasopharynx).

• Children with significant predisposing factors (eg, cleft palate) acquire infections so frequently that some authors advocate the routine placement of polyethylene tubes in their tympanic membranes to maintain aeration of the middle ear.

CLINICAL

Section 3 of 12

History: Patients who can communicate usually describe feelings of pain or discomfort in the affected ear. However, most cases occur in children who are unable to communicate specific complaints.

• Acute otitis media

• Earache

• Fever (not required for the diagnosis)

• Accompanying or precedent URI symptoms (very common)

• Decreased hearing

• Acute otitis media in infants

• Infants may be asymptomatic.

• Irritability may be the only symptom.

• Serous OME

• Patients are usually asymptomatic

• Decreased hearing may be demonstrated on audiometry.

Physical: If the canal is clean and if the patient is cooperative, physical examination is easy. If the canal is occluded with cerumen or debris, if the canal is anatomically small, or if the patient is unable to cooperate, examination may be difficult.

• Inflammation of the tympanic membrane and diminished movement of the membrane with insufflation or decreased visibility of the landmarks of the middle ear are the hallmarks of otitis media.

• Injection of the membrane is common in crying infants, and it may mislead the casual observer to believe the patient has acute otitis media. Therefore, pneumatic otoscopy is helpful in examining any patient with an injected tympanic membrane.

• A history suggestive of acute otitis media and an ear canal full of purulent exudate is usually considered sufficient to diagnosis acute otitis media with perforation.

• Acute otitis media should be painless. If pain is present, suspect that a foreign body in the ear canal is causing the infection or that the patient has otitis externa.

• Remove cerumen and other debris from the canal, as necessary, to allow clear visualization of the entire tympanic membrane.

• Removal may be difficult if the patient is uncooperative.

• Irrigation may be useful, as it may soften and dislodge cerumen so that it can be removed more easily.

• Soft plastic curettes are preferred to metal ones, but a firm tool may be necessary to remove a hard block of cerumen.

• Patients may require a referral if sufficient time and resources are not available for the proper and safe removal of cerumen.

• Care should be taken to avoid perforation of the tympanic membrane.

• The association between bacterial conjunctivitis and otitis media is well described.

• Any patient with purulent conjunctival exudate should receive thorough examination of the tympanic membranes.

• Sinusitis and purulent rhinitis frequently accompany otitis in children and infants.

Causes: Anatomic and immunologic factors in the presence of acute infection are the main causes of acute otitis media.

• Pneumococcus species, Haemophilus influenzae (untypeable), and Moraxella species are the bacteria most commonly involved in otitis media.

• Less common causes are other bacteria, Mycoplasma species, and viruses.

• Sterile effusions occur in approximately 20% of cases studied.

• Risk factors for otitis media have been identified.

• Daycare leads to an increased incidence of URIs.

• Bottle-feeding increases the incidence compared with breastfeeding.

• Smoking in the household clearly increases the incidence of all forms of respiratory problems in childhood.

• Male sex is a minor determinant of infection.

• A family history of middle ear disease increases the incidence.

• Acute otitis media in the first year of life is a risk factor for recurrent acute otitis media.

DIFFERENTIALS

Section 4 of 12

Brain Abscess
Dysbarism
Foreign Bodies, Ear
Herpes Zoster
Herpes Zoster Oticus
Labyrinthitis
Mastoiditis
Otitis Externa
Peritonsillar Abscess
Sinusitis

Other Problems to be Considered:

Coexistent conjunctivitis
Acute hearing loss
Tympanosclerosis
Erythema caused by crying
Pain referred from the teeth or jaw
Bullous myringitis
Parotitis (ie, mumps)
Cavernous sinus thrombosis

WORKUP

Section 5 of 12

Lab Studies:

• No definitive laboratory examination exists; however, the WBC count may be elevated in association with any infection.

• Blood cultures are positive in only about 3% of febrile patients with acute otitis media and are not routinely recommended.

Imaging Studies:

• Imaging studies are not valuable for diagnosis of acute otitis media.

• Radiography and/or CT scanning of the mastoid air cells may be helpful in select cases of suspected mastoiditis.

Other Tests:

• Tympanometry is easy to perform on any ear. Even when the tympanic membrane cannot be visualized, the results indicate the presence or absence of MEE.

• The findings cannot be used to differentiate between acute otitis media and chronic serous OME.

• Tympanometry cannot be recommended as a routine screening test for acute otitis media. However, in a patient in whom examination is difficult, normal tympanometric results may help rule out acute otitis media.

• Hearing tests are not helpful in diagnosing acute otitis media.

• Nasopharyngoscopy may reveal anatomic factors involved in acute otitis media and show purulent matter at the nasal opening of the eustachian tube, but the findings are of no acute diagnostic value.

Procedures:

• Tympanocentesis with a needle and syringe may be appropriate in an immunocompromised patient or in patients with persistent fever in the face of antibiotic therapy to delineate the etiology of an acute otitis media.

• If acute otitis media is present in infants younger than 2-3 months, some authors recommend tympanocentesis.

• This procedure often is performed by the ear, nose, and throat (ENT) consultant.

• Myringotomy is indicated only for patients with intractable pain.

TREATMENT

Section 6 of 12

Emergency Department Care:

• According to AAP and AAFP guidelines for the treatment of acute otitis media, an observation period may be recommended depending on the patient's age, the diagnostic certainty, and the severity of illness.

• Diagnostic certainty is based on all 3 of the following criteria: acute onset, MEE, and middle ear inflammation.

• Severe illness is defined as moderate-to-severe otalgia or temperature greater than 39°C, whereas nonsevere illness is defined as mild otalgia and temperature less than 39°C.

• The following recommendations were made:

• Infants younger than 6 months should receive antibiotics.

• Children aged 6 months to 2 years should receive antibiotics if the diagnosis is certain. If the diagnosis is uncertain, an observation period can be considered if the illness is nonsevere, and antibiotic therapy can be considered for severe illness.

• Children aged 2 years and older should receive antibiotics if the diagnosis is certain and if the illness is severe. An observation period is an option when the diagnosis is uncertain or when it is certain and nonsevere.

• The observation option is a 48- to 72-hour period of symptomatic treatment with analgesics and without antibiotics, followed by reexamination.

• For an observation option to be considered, the parent must be able to communicate with the physician and have access to follow-up care whenever problems ensue or symptoms worsen.

• Pain management is an important part of treating acute otitis media, especially in the first 24 hours. Appropriate analgesics should be offered.

Consultations:

• In general, patients with acute otitis media seen in the ED should be referred to a primary care physician for follow-up care.

• Patients discharged with a full course of therapy should be reexamined 4-6 weeks after their initial presentation for evidence of middle ear aeration.

• Patients whose symptoms (eg, pain, fever) do not resolve within 48 hours of treatment should be reevaluated. Most treatment failures are due to compliance problems or anatomic factors rather than antibiotic resistance.

MEDICATION

Section 7 of 12

In the United States, antibiotic therapy is usually prescribed for patients with any hint of acute otitis media. In other parts of the world, many patients are monitored for evidence of spontaneous clearing or onset of complications instead of routine antibiotic use. Studies have shown that antibiotics provide little benefit beyond placebo in mild cases of acute otitis media. Antipyretics and analgesics may be necessary and should be prescribed liberally. Steroids, decongestants, and antihistamines are not effective in the treatment of acute otitis media, and they may cause complications.

Drug Category: Antibiotics -- Empiric coverage for Streptococcus pneumoniae, H influenzae, and Moraxella species may be provided to children; adults have H influenzae infection less frequently than children. Controlled studies of effective antibiotics in the United States have demonstrated 90-95% efficacy. Studies in other parts of the world demonstrate about 80% resolution with observation alone. The AAP and AAFP recommend the use of high doses and short courses of amoxicillin.

If antibiotic therapy is chosen, amoxicillin 80-90 mg/kg/d is the antibiotic of choice. The length of treatment is 10 days for younger children and patients with severe illness, and a 5- to 7-day course is recommended for children older than 6 years. If additional beta-lactamase–positive H influenzae and/or Moraxella catarrhalis coverage is desired, high-dose amoxicillin and clavulanate potassium is recommended.

If the patient is allergic to amoxicillin, alternatives are cefdinir, cefpodoxime, or cefuroxime if the allergic reaction is not a type 1 hypersensitivity. Patients with type 1 hypersensitivity should be given azithromycin or clarithromycin. Other alternatives are clindamycin and ceftriaxone given intravenously or intramuscularly. Ceftriaxone 50 mg/kg/d is recommended for children who are unable to take oral antibiotics and for patients with compliance problems.

In patients whose condition fails to improve after initial antibiotic therapy, a 3-day course of ceftriaxone offers outcomes better than those of a 1-day course.

Drug Name	Amoxicillin (Amoxil, Biomox) -- Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria. Inexpensive and effective, even in populations with certain highly resistant bacteria.
Adult Dose	250-500 mg PO q8h
Pediatric Dose	80-90 mg/kg/d PO divided q8h for 10d in younger children and in patients with severe disease
Contraindications	Documented hypersensitivity
Interactions	Reduces efficacy of oral contraceptives
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in renal impairment; use in Ebstein-Barr viral mononucleosis increases risk of severe rash

Drug Name	Amoxicillin and clavulanate potassium (Augmentin) -- Drug combination treats bacteria resistant to beta-lactam antibiotics. For children > 3 mo, base dosing protocol on amoxicillin content. Because of different amoxicillin and clavulanate ratios in 250-mg tab (250/125) vs 250 mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.
Adult Dose	500-875 mg PO q12h PO or 250-500 mg PO q8h
Pediatric Dose	90 mg/kg (amoxicillin) with 6.4 mg/kg (clavulanate) divided PO q12h
Contraindications	Documented hypersensitivity
Interactions	Coadministration with warfarin or heparin increases risk of bleeding
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Give for minimum of 10 d to eliminate organism and prevent sequelae (eg, endocarditis, rheumatic fever); after treatment, perform cultures to confirm eradication of streptococci

Drug Name	Cefuroxime (Ceftin) -- Second-generation cephalosporin maintains gram-positive activity of first-generation cephalosporins; adds activity against Proteus mirabilis, H influenzae, Escherichia coli, Klebsiella pneumoniae, and M catarrhalis. Condition of patient, severity of infection, and susceptibility of microorganism determines proper dose and route.
Adult Dose	125-500 mg PO q12h
Pediatric Dose	30 mg/kg PO q12h
Contraindications	Documented hypersensitivity
Interactions	Disulfiramlike reactions may occur when alcohol consumed within 72 h after dose; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patient receiving potent diuretics, such as loop diuretics; coadministration with aminoglycosides increase nephrotoxic potential
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Reduce dosage by half if creatinine clearance 10-30 mL/min and by three quarters if <10 mL/min (high doses may cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy

Drug Category: Analgesics -- Relief of pain is one of the prime functions of effective treatment. Oral analgesics or topical medications may be required for relief of pain. Appropriate doses of acetaminophen or ibuprofen are available in tablet or liquid form. Codeine may be used as an ancillary agent; however, it may provoke emesis or constipation.

Drug Name	Benzocaine (Americaine, Cylex) -- Inhibits neuronal membrane depolarization, blocking nerve impulses. Drops may be used as local anesthetic, with some benefit.
Adult Dose	2-3 gtt q4-6h prn
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Not intended for use when infection present

Drug Name	Acetaminophen (Tylenol, Tempra, Panadol) -- Used worldwide for antipyretic effects and mild analgesic effects. DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or with oral anticoagulation. May be used with ibuprofen for additive effects.
Adult Dose	650 mg PO q4-6h; not to exceed 4 g/d
Pediatric Dose	15-20 mg/kg/dose q4-6h; not to exceed 2.6 g/d
Contraindications	Documented hypersensitivity; G-6-PD deficiency
Interactions	Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Hepatotoxicity possible in chronic alcoholism at various doses; severe or recurrent pain or high or continued fever may indicate serious illness; contained in many OTC products, and combined use of products may result in cumulative doses exceeding recommended maximum

Drug Name	Ibuprofen (Motrin, Ibuprin, Advil) -- DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Approved for use in children. Available as inexpensive liquid form, allowing for effective dosing in infants.
Adult Dose	400-800 mg PO q6-8h for pain or fever; not to exceed 3.2 g/d
Pediatric Dose	10 mg/kg PO (100 mg/5 cc) q6h for pain or fever
Contraindications	Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; closely monitor PT (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	At therapeutic doses, can cause renal failure and/or gastric upset (more common in elderly persons but also described in children); category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

FOLLOW-UP

Section 8 of 12

Further Outpatient Care:

• Most cases of otitis media are self-limited. The incidence of complications is high enough that all patients should be encouraged to have a follow-up visit with their regular physician or clinic approximately 14-21 days after the initial visit.

• Patients with persistent pain or fever should be reexamined within 48 hours.

• If an observation period is chosen, failure to improve within 48-72 hours should prompt initiation of antibiotic therapy.

• If antibiotics were started initially and if the patient's condition fails to improve, the antibiotic should be changed, and compliance must be emphasized.

• Infants with frequent recurrences may benefit from daily antibiotic prophylaxis with sulfamethoxazole or amoxicillin for a period of several months.

• An osteopathic manipulation technique (ie, Galbreath technique) has been described. It may help some patients open their eustachian tubes and treat or prevent middle ear fluid accumulation. No blinded studies of this technique have been performed.

Deterrence/Prevention:

• Breastfeeding decreases the incidence of acute otitis media.

• Cigarette smoking in the household should be eliminated.

• In adults and older children, regular exercises to increase upper airway pressure and to force inflation of the middle ear may be useful (see the reference to the Galbreath technique above). Blowing up balloons is effective in some small children.

Complications:

• Serous OME is the most common complication.

• It may cause mild discomfort in some patients; however, if it is bilateral, hearing loss with resultant speech delay may occur in infants.

• Treatment of this condition is not the responsibility of an ED physician. The patient should be referred.

• Mastoiditis used to be a common complication, but now with antibiotic treatment it is rare. Patients with any mastoid tenderness or edema accompanying otitis should be treated aggressively in consultation with an ENT specialist.

• Perforation of the tympanic membrane is a frequent, but usually not serious, complication. Treatment is not changed from that described above, but follow-up care is more important. With proper treatment, most perforations heal within a couple of weeks, with no residual complications.

• Intracranial complications, such as epidural abscess or cavernous sinus thrombosis, are rare and should be treated with admission to a critical care unit. They usually present primarily rather than as a late complication of treated otitis.

Prognosis:

• The prognosis of patients with acute otitis media is excellent. However, patients and/or their parents still should be encouraged to finish the prescribed medication and to keep their follow-up appointments.

• Symptoms usually improve within 24 hours and almost always within 48-72 hours.

Patient Education:

• Parent education by the physician is the most important factor contributing to the proper use of medications and follow-up care.

• Failure to finish a course of antibiotic therapy usually occurs because the prescribing physician fails to explain the importance of the medication and the need to finish the entire course of therapy.

• Therefore, the physician must discuss the process and the specific treatment plan with the patient and/or the parents.

• For excellent patient education resources, visit eMedicine’s Ear, Nose, and Throat Center . Also, see eMedicine’s patient education article Earache.

MISCELLANEOUS

Section 9 of 12

Medical/Legal Pitfalls:

• Diagnosis and treatment of otitis media are rare causes of legal problems. However, failure to diagnose meningitis in a sick child with associated otitis can lead to inadequate treatment for the meningitis and significant legal problems for the provider.

• Do not allow the presence of acute otitis media deter further diagnostic workup if the patient appears significantly ill.

• Failure to recognize contiguous spread to mastoid air cells is a pitfall.

TEST QUESTIONS

Section 10 of 12

CME Question 1: An adult presents with ear pain and a fever. The patient's tympanic membrane is shown. What is the most appropriate treatment?

A: Myringotomy and tube placement
B: Needle aspiration of fluid for cultures
C: Intranasal steroids
D: Intravenous gentamicin for 10 days
E: Oral amoxicillin for 10 days

The correct answer is E: Oral antibiotics are as effective as myringotomy, and they have fewer complications. Intravenous antibiotics are not indicated unless the patient is immunocompromised.

CME Question 2: What finding should be present to diagnose otitis media in a crying, febrile infant?

A: Red tympanic membrane
B: History of previous otitis
C: Decreased motion of tympanic membrane on insufflation with injection
D: Obstruction of canal by cerumen
E: Apparent pulling of the ear by the patient

The correct answer is C: Erythema alone may be caused by a fever and crying. Pulling is not correlated with the presence or absence of otitis. Cerumen indicates the need for its removal to allow adequate examination. Previous history does not define the cause of any given episode of febrile illness. Insufflation should demonstrate decreased motion of the tympanic membrane in conjunction with inflammation, proving the diagnosis of acute otitis media.

Pearl Question 1 (T/F): The most common problem with the proper diagnosis of otitis media is a small ear canal.

The correct answer is False: Failure to remove cerumen and adequately clean the canal leads to inadequate examination and is the most common problem.

Pearl Question 2 (T/F): Diarrhea is the most common reason why parents fail to administer the full course of antibiotic therapy to their child with otitis media.

The correct answer is False: Failure to finish a course of antibiotic therapy usually occurs because the prescribing physician fails to explain the importance of the medication and the need to finish the entire course of therapy.

Pearl Question 3 (T/F): Amoxicillin is the best antibiotic for acute childhood otitis media on the basis of cost, adverse reactions, and sensitivity of the usual organisms.

The correct answer is True: The incremental benefit of antibiotics in most patients with mild otitis is so low that the safest and cheapest antibiotic should be used; otherwise, complications of treatment could be worse than complications of the disease.

Pearl Question 4 (T/F): Acute otitis media (AOM) usually arises as a complication of a preceding viral upper respiratory infection (URI).

The correct answer is False: Accompanying or precedent URI symptoms are common with presentation of AOM.

PICTURES

Section 11 of 12

Caption: Picture 1. Drawing of a normal right tympanic membrane. Note the outward curvature of the pars tens (*) of the eardrum. The tympanic annulus is indicated anteriorly (a), inferiorly (i), and posteriorly (P). M = long process of the malleus; I = incus; L = lateral (short) process of the malleus.
	View Full Size Image
	eMedicine Zoom View (Interactive!)
Picture Type: Image
Caption: Picture 2. Tympanic membrane of a person with 12 hours of ear pain, slight tympanic membrane bulge, and slight meniscus of purulent effusion at bottom of tympanic membrane. Reproduced with permission from Isaacson G: The natural history of a treated episode of acute otitis media. Pediatrics 1996; 98(5): 968-7. (See also Image 3.)
	View Full Size Image
	eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 3. Days after onset of symptoms, vessels continue across pars tensa, and a fluid layer of pus is noted. Reproduced with permission from Isaacson G: The natural history of a treated episode of acute otitis media. Pediatrics 1996; 98(5): 968-7. (See also Image 2.)
	View Full Size Image
	eMedicine Zoom View (Interactive!)
Picture Type: Photo

BIBLIOGRAPHY

Section 12 of 12

• American Academy of Pediatrics: Diagnosis and management of acute otitis media. Pediatrics 2004 May; 113(5): 1451-65[Medline].
• Barnett ED, Teele DW, Klein JO, et al: Comparison of ceftriaxone and trimethoprim-sulfamethoxazole for acute otitis media. Greater Boston Otitis Media Study Group. Pediatrics 1997 Jan; 99(1): 23-8[Medline].
• Berman S, Byrns PJ, Bondy J, et al: Otitis media-related antibiotic prescribing patterns, outcomes, and expenditures in a pediatric medicaid population. Pediatrics 1997 Oct; 100(4): 585-92[Medline].
• Canafax DM, Yuan Z, Chonmaitree T, et al: Amoxicillin middle ear fluid penetration and pharmacokinetics in children with acute otitis media. Pediatr Infect Dis J 1998 Feb; 17(2): 149-56[Medline].
• Cantor RM: Otitis externa and otitis media. A new look at old problems. Emerg Med Clin North Am 1995 May; 13(2): 445-55[Medline].
• Cohen R, Levy C, Boucherat M, et al: A multicenter, randomized, double-blind trial of 5 versus 10 days of antibiotic therapy for acute otitis media in young children. J Pediatr 1998 Nov; 133(5): 634-9[Medline].
• Heikkinen T, Thint M, Chonmaitree T: Prevalence of various respiratory viruses in the middle ear during acute otitis media. N Engl J Med 1999 Jan 28; 340(4): 260-4[Medline].
• Heikkinen T, Chonmaitree T: Viral-Bacterial Synergy in Otitis Media: Implications for Management. Curr Infect Dis Rep 2000 Apr; 2(2): 154-159[Medline].
• Howie VM: Otitis media. Pediatr Rev 1993 Aug; 14(8): 320-3[Medline].
• Isaacson G: The natural history of a treated episode of acute otitis media. Pediatrics 1996 Nov; 98(5): 968-71[Medline].
• Kaleida PH, Casselbrant ML, Rockette HE, et al: Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial. Pediatrics 1991 Apr; 87(4): 466-74[Medline].
• Lund WS: A review of 50 cases of intracranial complications from otogenic infection between 1961 and 1977. Clin Otolaryngol 1978 Nov; 3(4): 495-501[Medline].
• Mandel EM, Casselbrant ML, Rockette HE, et al: Efficacy of 20- versus 10-day antimicrobial treatment for acute otitis media. Pediatrics 1995 Jul; 96(1 Pt 1): 5-13[Medline].
• Olson AL, Klein SW, Charney E, et al: Prevention and therapy of serous otitis media by oral decongestant: a double-blind study in pediatric practice. Pediatrics 1978 May; 61(5): 679-84[Medline].
• Pratt-Harrington D: Galbreath technique: a manipulative treatment for otitis media revisited. J Am Osteopath Assoc 2000 Oct; 100(10): 635-9[Medline].
• Rosenfeld RM: An evidence-based approach to treating otitis media. Pediatr Clin North Am 1996 Dec; 43(6): 1165-81[Medline].
• Rosenfeld RM, Vertrees JE, Carr J, et al: Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr 1994 Mar; 124(3): 355-67[Medline].
• Schutzman SA, Petrycki S, Fleisher GR: Bacteremia with otitis media. Pediatrics 1991 Jan; 87(1): 48-53[Medline].
• Teele DW, Pelton SI, Klein JO: Bacteriology of acute otitis media unresponsive to initial antimicrobial therapy. J Peds 1981; 98: 537-539[Medline].

eMedicine Journals > Emergency Medicine > Ear, Nose, And Throat > Otitis Media

Please email us with any comments you have on our new chapter format.

Author Information | Introduction | Clinical | Differentials | Workup | Treatment | Medication | Follow-up | Miscellaneous | Test Questions | Pictures | Bibliography