What is the Most Reliable Indicator of Acute Otitis Media?

Patient Presentation
A 9-month-old male came to clinic after 2 days of clear rhinorrhea. He woke in the night crying and was difficult to console. He had a fever to 38.7 degrees Celsius and responded to an appropriate dose of acetaminophen. He then returned to sleep.
In the morning he was cranky and again had some relief with acetaminophen. He breastfed but seemed uncomfortable with it.
The past medical history revealed no previous ear infections, but a couple of upper respiratory infections.
The review of systems wss negative including rash, cough, emesis or diarrhea.
The pertinent physical exam showed a tired-appearing male with a temperature of 38.3 degree Celsius, respiratory rate = 32, and heart rate = 124. His growth parameters were 10-50%.
HEENT revealed copious clear rhinorrhea, normal pharynx, and s right tympanic membrane that was red, bulging and normal landmarks were not visible. Pneumatic otoscopy showed no movement of the right tympanic membrane.
The left tympanic membrane was grey with clear fluid and an air-fluid level visible approximately 50% of the way to the top of the tympanic membrane. There was decreased mobility of the left tympanic membrane. He had shoddy anterior cervical nodes.
The rest of his examination was normal.
The diagnosis of right acute otitis media was made and he was begun on Amoxicillin 80-90 mg/kg/day for 10 days. He was to follow-up in ~ 6 weeks to re-check his ear and receive an influenza vaccination.

Acute otitis media (AOM) is one of the most common infectious diseases in childhood.
It significantly impacts the health of children and causes a social burden due to indirect costs in lost time in school and work.
Costs in 1995 in the United States were estimated at $1.96 billion directly and $1.02 billion indirectly.

AOM is an inflammatory process that affects the mucosa of the middle ear and is characterized by fever and otalgia.
The inflammatory process may continue with build-up of pus in the middle ear leading to rupture of the tympanic membrane and otorrhea.
It is caused by both viruses and bacteria. Common viral pathogens are adenovirus, Influenza type A and Respiratory Syncytial Virus.
Common bacteria include Streptoccus pneumoniae, Moraxella catarrhalis, and Haemophilus influenza type B.
Some locations are seeing a decrease in Haemophilus influenza type B, presumably due to vaccination.

AOM should be treated with pain control, and watchful waiting and/or antibiotics depending on the age and severity of symptoms.
The American Academy of Pediatrics Clinical Practice Guideline published in 2004 has specific recommendations (see To Learn More below).

Learning Point
AOM can be diagnosed when the following 3 elements are present:

  • History of recent, usually abrupt onset of acute signs and symptoms,
    e.g. otalgia, fussiness, crying, fever

  • Middle ear effusion documented by any of the following:
    • Tympanic membrane bulging
    • Mobility that is limited or absent
      often documented by pneumatic otoscopy, sometimes tympanometry is used, tympanocentesis is sometimes used

    • Air-fluid level presence behind the middle ear
    • Otorrhea
  • Middle ear effusion signs and symptoms documented by any of the following
    • Tympanic membrane erythema
    • Otalgia that is referable to the ears and that interferes with activities or sleep

The most reliable diagnostic criteria are bulging of the tympanic membrane, otalgia, and otorrhea.
Most children present without otorrhea, so for those without otorrhea, bulging of the tympanic membrane is the best predictor of AOM especially when combined with color and mobility.

AOM is distinctly different from otitis media with effusion and recurrent AOM.
Otitis media with effusion is defined as fluid in the middle ear without signs of symptoms of acute ear infections.
Recurrent acute otitis media is defined as 3 or more AOM infections in 6 months or more than 4 episodes in a year. Patients must be disease free in between these AOM episodes.

Questions for Further Discussion
1. What are the indications for observation (i.e. watchful waiting) in children with AOM?
2. What are the indications for treatment with pressure-equalizing tubes (i.e. tympanostomy tubes, grommets)?
3. What are efficacious treatments for otitis media with effusion?
4. How does breastfeeding, tobaco exposure and vaccination potentially impact the frequency of AOM?>br>

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for this topic: Ear Infections

To view current news articles on this topic check Google News.

American Academy of Pediatrics. Otitis Media with Effusion. Pediatrics. 2004;113;1412-1429.

American Academy of Pediatrics. Diagnosis and Management of Acute Otitis Media. Pediatrics. 2004:113;1451-1465.

Lous J, Burton MJ, Felding JU, Ovesen T, Rovers MM, Williamson I. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. (Protocol)
The Cochrane Database of Systematic Reviews. 2006 Issue 3

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.

    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    November 13, 2006