AOM is the most common illness prompting office visits and antimicrobial prescriptions in childhood Clinical practice guidelines have encouraged a stricter diagnostic threshold for AOM, and immunization with PCV7 and influenza vaccines may have reduced the actual incidence AOM is defined as the rapid onset of signs and symptoms of inflammation in the middle ear It is considered severe if there is moderate to severe otalgia or fever >39°C (102.2°F) Aside from ear pain, reported in only 50% to 60% of children with AOM, symptoms of AOM such as irritability, ear tugging, sleep disruption, and fever are variable and nonspecific Using strict but appropriate otoscopic criteria, a majority of children whose parent suspects AOM in fact have uncomplicated upper respiratory infection (URI) Examination of the TM is one of the most difficult clinical skills to master Agreement on AOM diagnosis between otolaryngologists, the gold standard, and pediatricians or family physicians is abysmal Improved training in the diagnosis of AOM and careful physical examination is clearly warranted In younger children with respiratory symptoms, fever, or specific ear symptoms, adequate visualization of the TM is required Despite the increasing pressure to manage and make a disposition for patients quickly, clinicians must take the time to accurately determine if AOM is present Removal of cerumen with saline irrigation, peroxide-containing ear drops, docusate sodium syrup, and/or curettage will be a frequent procedure for clinicians caring for children Immobilization of the uncooperative child may be required and proper equipment must be available Bulging of the TM is the physical finding most specific for the presence of a bacterial pathogen in middle ear fluid ( Fig 58.2 A–D ) In children with acute symptoms, impaired TM mobility with pneumatic otoscopy and the presence of cloudy middle ear fluid are also strongly correlated with bacterial infection A TM that appears hemorrhagic or strongly red is associated with AOM, but lesser degrees of redness are not useful diagnostically Occasionally, examination of a child with AOM will reveal bullae on the TM The organisms responsible for “bullous myringitis” are not significantly different from other cases of AOM and treatment should be similar Children with AOM and TM perforation may present with purulent otorrhea that prevents adequate visualization of the TM Otitis externa can usually be excluded on clinical grounds, so a presumptive diagnosis of AOM with perforation can be made Otitis media with effusion (OME) is the current term for a condition described by fluid in the middle ear cavity without signs and symptoms of acute