AOM occurs most predominantly between the ages of 3 to 18 months as it commonly affects children 2 years or younger [1]. Moreover, some children are prone to developing recurrent episodes.

Neonates with AOM present with irritability and/or trouble with feeding. Older children with this condition typically have fever, ear pain with ear tugging, conductive hearing loss, and possibly an upper respiratory tract infection (URTI). Other possible symptoms include nausea, emesis, diarrhea, and signs related to URTI. Note that hearing loss is common in both children and adults with AOM as well as otitis media with effusion (OME). Hearing does eventually recover [2].

In cases with tympanic membrane perforation, exudative discharge leaks out for a day or two and the pain quickly subsides.

Risk factors

It is important to consider the risk factors when evaluating the patient. These include prematurity, low birth weight, immunosuppression, allergies, exposure to tobacco and environmental pollutants, colder climates, low socioeconomic status, positive family history, and certain racial backgrounds (such as Native Americans). Children with craniofacial defects and neuromuscular disease may be predisposed as well. Finally, pacifier and bottle use, prone sleeping position, and daycare attendance are other contributing factors.

Physical exam

Notable findings suggestive of inflammation on pneumatic otoscopy include an erythematous tympanic membrane, purulent or serosanguinous effusion in the middle ear, and decreased mobility of the tympanic membrane. Bulging of the membrane is also observed.

• Fever

  Hearing symptoms were common (67%) but fever (32%) and retroauricular symptoms were uncommon in AOM. Fever (44%) and mastoid tenderness (65%) were common in AM. Patients with LM underwent the most mastoidectomies (54%). [ncbi.nlm.nih.gov]

  The combination of these signs with ear pain or fever confirms the diagnosis of AOM. [medicalguidelines.msf.org]

  Review after 48 hours 17. 48 hours review • Earache fever persists: change to higher antibiotic. • If T.M. is bulging perform myringotomy. [slideshare.net]

  Only fever was an exception, because children with bilateral AOM had fevers more often and fevers that were slightly higher. This was a new finding. [pediatrics.aappublications.org]

• Malaise

  The patient may also have systemic features, such as fever and malaise. Although AOM is a common condition in young children, it can affect all age groups, including neonates. [teachmesurgery.com]

  Malaise. Irritability, crying, poor feeding, restlessness. Fever. Coryza/rhinorrhoea. Vomiting. Signs Examination may reveal: High temperature (febrile convulsions may be associated with the temperature rise in AOM). [patient.info]

  Symptoms Some of the common symptoms of otitis media that a parent should look out for are: Rubbing ear Earache Excessive crying Diarrhoea Fever Vomiting Vertigo Other signs and symptoms of an upper respiratory tract infection (e.g. rhinorrhoea, cough, malaise [healthengine.com.au]

• Recent Upper Respiratory Infection

  History of a recent upper respiratory infection is common. Treatment Since AOM is usually self-limiting and resolves in 1 to 2 weeks without antibiotics, the best approach is to watch and wait. [medical-dictionary.thefreedictionary.com]

• Severe Abdominal Pain

  A female aged 9 years with a recent episode of acute otitis media (AOM) presented to her primary care physician with complaints of severe abdominal pain with right lower quadrant rebound tenderness, suggestive of an acute surgical abdomen. [ncbi.nlm.nih.gov]

• Malocclusion

  RAOM showed better outcomes in children with dental malocclusion wearing a mandibular repositioning device. Dental malocclusion in children with RAOM may play a role in the pathogenesis of Eustachian tube dysfunction. [ncbi.nlm.nih.gov]

• Otalgia

  The diagnosis is based on acute onset of symptoms such as otalgia and fever, middle ear inflammation such as erythema of the tympanic membrane, and middle ear effusion. [ncbi.nlm.nih.gov]

  otalgia, fever, anorexia) with signs of middle ear inflammation (e.g., bulging tympanic membrane, effusion). Mild unilateral infections can be managed without antibiotics, as they are often self-limiting. [amboss.com]

• Ear Discharge

  Streptococcus pneumoniae and Haemophilus influenzae were cultured from the purulent ear discharge. The final diagnosis was locked-in syndrome consecutive to inflammatory changes compressing the basilar artery. [ncbi.nlm.nih.gov]

  Perforation of the tympanic membrane can occur, with associated purulent ear discharge. Investigations Investigations are rarely required in the evaluation of AOM. [gponline.com]

  Aural toilet for ear discharge 6. Hot fomentation for severe earache 7. Review after 48 hours 17. 48 hours review • Earache fever persists: change to higher antibiotic. • If T.M. is bulging perform myringotomy. [slideshare.net]

• Tinnitus

  The limited evidence available suggests that acute otitis media with tinnitus and/or bacterial pathology may have an increased risk of sudden sensorineural hearing loss, which is consistent with the case described. [ncbi.nlm.nih.gov]

  Associated features - Some hearing loss, tinnitus and fever. Small children may appear unwell, crying and be pulling at the affected ear. Remember - Document facial nerve exam, neurological status and ear examination including mastoid area. [entsho.com]

  Stage of pre suppuration • SYMPTOMS : Marked ear-ache(throbbing nature) Deafness & tinnitus High degree fever & restlessness • SIGNS : Congested pars tensa Cart Wheel appearance of T.M Tuning fork test conductive loss Bacteria invade tympanic cavity Hyperemia [slideshare.net]

  Additional information on balance disorders can be found at: Tinnitus Tinnitus is the medical term for hearing noise when there is no outside source of the sound. [otonomy.com]

• Hearing Problem

  RESULTS: Recurrent acute otitis media subjects reported hearing problems comparable to those of the controls. Pure tone audiometry, at 125-8000 Hz, did not differ between groups. [ncbi.nlm.nih.gov]

  In general, otitis media is not serious and does not normally cause permanent hearing problems if treated properly. Most often, otitis media is cured in the home by means of medication. [hear-it.org]

  Three main signs of an acute middle ear infection include sudden onset of the illness with severe earache, fever, hearing problems and general weakness, a red eardrum, and an eardrum that bulges outward, does not move freely and is not transparent, which [informedhealth.org]

  The patient should be re-evaluated at two weeks for hearing problem and response. Analgesics and antipyretics like paracetamol can be given in the initial period. Antihistaminics have not been found to be useful in AOM and are not recommended. [jpgmonline.com]

• Erythematous Tympanic Membrane

  Physical exam Notable findings suggestive of inflammation on pneumatic otoscopy include an erythematous tympanic membrane, purulent or serosanguinous effusion in the middle ear, and decreased mobility of the tympanic membrane. [symptoma.com]

  Normal Tympanic Membrane Pink Tympanic Membrane, often seen with fever or upper respiratory tract infections Bulging and erythematous Tympanic Membrane in AOM Otitis Media with Effusion "glue ear" Middle ear effusion Loss of TM landmarks, particularly [rch.org.au]

  Welleschik [CC-BY-SA-3.0], via Wikimedia Commons Figure 2 – An erythematous Tympanic Membrane in AOM, as viewed on otoscope Common symptoms of AOM include pain, malaise, fever, and coryzal symptoms, lasting for a few days. [teachmesurgery.com]

  Erythematous tympanic membranes may be due to viral infection, crying, or efforts to remove cerumen. Fever or irritability may or may not be present. [coreem.net]

• Dizziness

  Other symptoms include trouble hearing, fever, fluid drainage from ears, dizziness and congestion. [clinicaladvisor.com]

  […] local policy Combination antibiotic and steroid ear drops Good analgesia IV fluids if the patient is vomiting or dehydrated Artificial tears and eye lubrication if there is facial palsy Short term vestibular sedative eg prochlorperazine if there is dizziness [entsho.com]

  Clinical course and diagnosis The symptoms of otitis media are earache, discharge from the ear, hearing loss, ear popping, ear fullness, dizziness, and fever. [ncbi.nlm.nih.gov]

  Clinically it is difficult to diagnose, patients can present with signs of intracranial hypertension or hydrocephaly such as intense headache, photophobia, dizziness and nausea. [elsevier.es]

  ENT specialists treat conditions such as ear infection, hearing loss, dizziness, ringing in the ears (called tinnitus), ear, face, or neck pain, and more. [entnet.org]

• Vertigo

  Clinical features Severe vertigo, nausea, and vomiting Hearing loss Nystagmus towards healthy ear for weeks to months Diagnostics Change of lateralization in Weber's test Audiometry: sensorineural hearing loss Treatment Peripheral facial palsy Otogenic [amboss.com]

  […] policy Combination antibiotic and steroid ear drops Good analgesia IV fluids if the patient is vomiting or dehydrated Artificial tears and eye lubrication if there is facial palsy Short term vestibular sedative eg prochlorperazine if there is dizziness/vertigo [entsho.com]

  Benign Paroxysmal Positional Vertigo (BPPV) Benign paroxysmal positional vertigo, or BPPV, is the most common inner ear problem and cause of vertigo, or false sense of spinning. [entnet.org]

  There are many causes and types of balance disorders including benign positional vertigo, labyrinthitis, vestibular neuritis, and Ménière’s disease. [otonomy.com]

• Febrile Convulsions

  In a small child with a high temperature there is a risk of febrile convulsions. This is discussed more fully in its own article. Rare complications include Petrositis. [patient.info]

To establish the diagnosis, the clinician will evaluate the patient's clinical manifestations, history, and risk factors. Also crucial is the physical exam including otoscopy. Testing may be warranted in some cases as explained below.

According to clinical practice guidelines set forth by the American Academy of Pediatrics and the American Academy of Family Physicians [3], diagnostic criteria include the presence of tympanic membrane bulging, recent onset of otorrhea (in the absence of external otitis media), middle ear effusion, and ear pain or tugging.

Procedure

Tympanocentesis is performed through piercing of the tympanic membrane and aspiration of the contents. This procedure is indicated in infants less than 6 weeks of age since AOM in this age group may be attributed to unusual organisms. Additionally, patients with failed treatment or signs indicative of sepsis should undergo this procedure. Finally, some patients will need a culture to determine the appropriate management, especially with the emergence of antibacterial resistance hindering treatment [4].

Imaging

Computed tomography (CT) or magnetic resonance imaging (MRI) are obtained if complications are suspected.

• Haemophilus Parainfluenzae

  A case of Haemophilus parainfluenzae meningitis in a woman with a 3-day history of acute otitis media is reported. Her medical history included bladder cancer surgery. [ncbi.nlm.nih.gov]

1. Paradise JL, Rockette HE, Colborn DK, et al. Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life. Pediatrics. 1997; 99(3):318-33.
2. McDonald S, Langton Hewer CD, et al. Grommets (ventilation tubes) for recurrent acute otitis media in children. Cochrane Database of Systemic Reviews. 2008; (4):CD004741.
3. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013; 131(3):e964-99.
4. Block SL. Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media. The Pediatric Infectious Disease Journal. 1997; 16(4):449-56.