Children greater than years of age without severe otitis media can be observed off antibiotics Facial nerve palsies should prompt a thorough evaluation of the middle ear Young children with cochlear implants are at significantly increased risk of pneumococcal meningitis secondary to acute otitis media (AOM) Current Evidence Apart from viral infections of the upper respiratory tract, acute otitis media (AOM) is the most common head and neck infection in children and is the second most common diagnosis made in the ED It may occur as an isolated infection though it is commonly a complication of an upper respiratory tract infection Children with noninfected fluid in the middle ear (also called otitis media with effusion [OME] or serous otitis media or secretory otitis media) are at increased risk for AOM Other risk factors include day care attendance, exposure to secondhand smoke, and immunodeficiency states In addition to viral etiologies, the more common organisms causing acute otitis at all ages are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis Group A β-hemolytic streptococci is a less common etiology Other gram-negative organisms may occur in hospitalized patients who are younger than weeks or immunosuppressed Over the last decade, the American Academy of Pediatrics (AAP) and the Joint Committee of American Academy of Family Practitioners (AAFP) have developed guidelines to improve accuracy of diagnosis of AOM which were last modified in 2013 Based on the best available evidence in the literature, diagnosis of AOM can be made based on the presence of any one of the following three criteria: Moderate to severe bulging of tympanic membrane (TM) Acute onset otorrhea not due to otitis externa Mild bulging and >48 hours of ear pain or intense erythema of TM Clinical Considerations Clinical Recognition AOM should be suspected in any child who is irritable or lethargic, has a lowgrade fever, and has localized pain in the ear Older children may have rapid onset of severe ear pain However, younger patients may rub, tug, or hold the ear as a sign of otalgia Spontaneous perforation of the TM with purulent or sanguinous otorrhea may occur in less than hour after the onset of pain On examination, the TM is hyperemic and mobility is decreased The strongest predictor of AOM is the presence of a bulging TM that obliterates normal landmarks, whereas isolated hyperemia is least helpful in predicting the disease Infection with any bacteria including Mycoplasma pneumoniae may cause blebs on the lateral surface of the drum The vesicles of bullous myringitis are filled with clear fluid and are painful The appearance of the TM in AOM secondary to bacterial pathogens does not differ significantly from AOM of viral etiology Triage Considerations Children with altered mental status, high fevers, extreme pain, severe headache, or neurologic abnormalities should be evaluated promptly for complications associated with otitis Meningitis and intracranial abscesses are rare complications of otitis media Clinical Assessment Acute otitis media should be suspected in any patient with low-grade fevers, ear pain, and irritability Presentation may vary according to age, as younger patients tend to present with less-specific symptoms such as decreased oral intake and irritability, while pulling at the affected ear Older children can typically describe otalgia Alternative diagnoses such as external ear canal foreign body, middle ear effusion, otitis externa, and pharyngitis should be considered and relevant information gathered during the history A recent history of water exposure or pain externally should point the clinician toward a diagnosis of otitis externa Examination of the ear begins by inspection of the auricle and surrounding areas The external meatus should be visualized directly with a bright light after it is fully opened by pulling the pinna posteriorly and superiorly The tragus may be displaced forward by traction on the skin in front of the ear with the examiner’s other hand ( Fig 118.1 ) The ear canal can then be examined with a pneumatic otoscope, using the largest speculum that will fit in the meatus without discomfort Cerumen or debris occluding the ear canal should be removed with a curette or by repeated irrigation with body-temperature water (see Chapter 130 Procedures , section on Removal of a Foreign Body from the Ear) Irrigation of the canal should not be performed if a ventilating tube is in place or if a perforation of the TM is suspected FIGURE 118.1 The external meatus is opened by pulling the auricle in the posterior-superior direction and placing traction on the skin immediately in front of the tragus The TM should be evaluated for its appearance; part of the middle ear contents can usually be seen if the eardrum is translucent ( Fig 118.2 ) (see also Fig 58.2 ) Mobility should be evaluated with the pneumatic otoscope rather than visualization alone, as this can increase the accuracy of diagnosing middle ear pathology Pneumatic otoscopy is performed by applying positive and negative pressure to the TM, with the pneumatic otoscope fitted snugly into the ear canal The pressure applied to the ear can be varied by squeezing a rubber bulb (see Chapter 130 Procedures , section on Pneumatic Otoscopic Examination) Middle ear effusion is more likely to be present if the TM fails to move with this technique The ear of a neonate requires special attention to perform an adequate otologic examination The ear canal itself is narrow and collapsible Often, only the otoscopic speculum can be inserted, as positive pressure from the pneumatic bulb is used to distend the canal ahead of the advancing speculum The canal may be filled with vernix caseosa, which must be removed or irrigated out of the canal to permit visualization of the TM The neonate’s TM lies at a more oblique angle to the ear canal (compared with older children) and may make recognition of the TM and its landmarks more difficult Amniotic fluid may be present in the middle ear cavity for days to weeks after birth and should not be confused with middle ear infection unless other symptoms such as fever and irritability are present A variety of scoring systems have been developed to aid in the diagnosis of AOM, though none have been formally recommended by the AAP FIGURE 118.2 Right tympanic membrane Management The clinical diagnosis of AOM is made clinically and no additional laboratory or imaging studies are necessary Antibiotics prescribed for AOM account for 25% to 50% of all outpatient antibiotics and are partly responsible for the global increase in antibiotic-resistant organisms, especially S pneumoniae, H influenzae, and M catarrhalis As such, expert panels and various medical