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