Otitis Media, Acute

Presentation

In acute otitis media (AOM), adults and older children will complain of ear pain (and/or fever) that is usually rapid in onset. There may or may not be accompanying symptoms of upper respiratory tract infection. In the younger child or infant, parents may report irritability, decreased appetite, and sleeplessness, with or without fever or pulling at the ears. The real diagnosis comes not from symptoms or history but from tympanic membrane (TM) findings ( Figs. 36.1 and 36.2 ). The TM may show marked redness, but contrary to what many clinicians were taught during training, erythema of the TM is the least specific finding for AOM.

Expanding middle-ear effusion volume and intense inflammation produce the key TM findings that are essential for an AOM diagnosis. These findings point to fullness or a bulging TM, with decreased clarity of the bony landmarks and decreased mobility on pneumatic otoscopy. A normal TM snaps briskly like a sail filling with air from a sudden breeze. With fluid behind the TM, there will be either sluggish or no movement at all. A diagnosis of AOM also can be established if the TM has perforated and acute purulent otorrhea is present that is not attributable to otitis externa (see Chapter 35 ).

Note that increased vascularity or erythema is not sufficient to diagnose AOM but does strengthen the diagnosis by providing the identification of possible TM inflammation. Keep in mind that a child’s vigorous crying is a common cause of an erythematous TM that otherwise has normal findings. Therefore, under these circumstances, avoid diagnosing AOM if erythema of the TM is the only finding suggesting AOM.