Many symptoms associated with AOM, such as fever,

irritability, restless sleep, and crying, are neither sensitive

nor specific for AOM, and may be present in children with

a URI with or without AOM. The presence of ear pain

increases the relative risk of a patient having AOM.

Purulent drainage from the ear may be present with AOM

with tympanic membrane perforation or with otitis

externa. Previous episodes of AOM, including timing of

CHAPTER 52

Pars flaccida

Light

reflex

.A. Figure 52-1. Normal tympanic membrane. Cou rtesy Richard A. Chole, MD PhD

most recent infection and antibiotic use may influence

choice of therapy. Persistent fever and headache may be

signs of intracranial complications of AOM.

� Physical Examination

Fever, though nonspecific, is present in 50% of cases

of AOM. Careful examination of the head and neck,

including the oropharynx, teeth, jaw, and lymph nodes,

should be done to search for other causes of pain that may

be referred to the ear. Inspection of the pinna, tragus, and

external auditory canal, as well as palpation of the tragus,

should be performed. Pain with manipulation of the pinna

or tragus, in conjunction with purulent otorrhea and

inflammation of the external auditory canal, suggests otitis

externa. The mastoid process should be examined for swelling, erythema, and tenderness, signs of mastoiditis. With

mastoiditis, the pinna may also be displaced anteriorly.

Diagnosis of AOM or OME is made based on the

appearance of the tympanic membrane (TM) on otoscopic

examination, in conjunction with the clinical presentation.

Adequate visualization of a child's TM requires good

patient immobilization, typically with the child seated on

the parent's lap with the head immobilized against the

parent's chest, as well as use of the largest speculum that

will comfortably fit in the external auditory canal. Removal

of cerumen from the external auditory canal may be

required for good visualization of the TM and can be

accomplished with a cerumen scoop or gentle irrigation.

Ear irrigation should not be performed if there is s uspicion

for a perforated TM. The external auditory canal in

children may be narrow and tortuous, and the tympanic

membrane is located anteriorly and superiorly. Gentle

traction on the pinna in a posterior direction straightens

the ear canal and can aid in visualization of the TM. Once

adequate visualization is obtained, the following tympanic

membrane characteristics should be assessed: translucency

(translucent, opaque, partly opaque), color (clear/grey,

white, amber, red), position (normal, retracted, bulging),

and mobility (normal, decreased or absent). A normal

tympanic membrane is translucent and clear with a

colorless or pearly gray color, and the bony landmarks of

the middle ear are easily visible (Figure 52- 1). In addition,

a normal TM has a neutral position and brisk mobility

with positive and negative pressure on insufflation. Opacity

of the TM often obscures the bony landmarks and s uggests

the presence of fluid in the middle ear or another

abnormality of the TM (tympanosclerosis, cholesteatoma).

Other findings consistent with a middle ear effusion are an

air fluid level or bubbles behind the TM, a bulging TM,

decreased or absent mobility of the TM, or otorrhea. A

middle ear effusion is present with both OME and AOM.

Characteristics associated with OME include a normal or

retracted TM, clear, or amber color, and impaired mobility

on insufflation. Characteristics associated with AOM are a

bulging TM, a purulent effusion, and distinct erythema of

the TM with a middle ear effusion (Figure 52-2). Erythema

alone is a poor predictor of AOM because the TM may

Figure 52-2. I mage showing patient with acute

otitis media. Courtesy Richard A. Chole, MD PhD

appear pink or red with fever or crying. In addition, it is

important to distinguish between distinct erythema of the

TM itself (as in AOM) and increased vascularity with a red

appearance only in the areas of the blood vessels.

DIAGNOSTIC STUDIES

..... Laboratory

AOM is a clinical diagnosis, and laboratory studies are

usually not required. Gram stain and culture of middle ear

fluid obtained by tympanocentesis may be helpful in

directing antibiotic therapy in complicated or resistant

infections, but is not routinely performed.

..... Imaging

A computed tomography (CT) scan of the head may be

needed if there is concern for mastoiditis or other

intracranial complication.

MEDICAL DECISION MAKING

History and physical examination should be sufficient to

diagnose AOM and distinguish it from OME. If the

tympanic membrane is normal, consider alternative

causes of ear pain or fever (Figure 52-3). Inflammation of

the mastoid process with anterior displacement of the

pinna or other signs and symptoms of intracranial extension of infection should warrant investigation with a

head CT.