In acute otitis media, the tympanic membrane is usually bulging. In otitis media with effusion, it is typically retracted or in the neutral position. The tympanic membrane can be thickened in both acute otitis media and otitis media with effusion, thereby reducing visibility through it. A yellow or grayish middle ear effusion can be seen behind the tympanic membrane in either condition. Tympanometry and acoustic reflectometry each have attributes that make them valuable in providing information about the possible presence of a middle ear effusion.
Both instruments have portable models, allowing them to be carried from one examination room to another. Acoustic reflectometry has the advantage of not requiring a seal within the ear canal, which improves its usefulness in a child who is not cooperative. Tympanometry provides additional information about actual pressures within the middle ear space. The gold standard for the diagnosis of acute otitis media in clinical trials is tympanocentesis for determination of the presence of middle ear fluid, with subsequent culture for identification of causative pathogens.
In selected cases of refractory or recurrent middle ear disease, however, tympanocentesis can serve to improve diagnostic accuracy, guide treatment and avoid unnecessary medical or surgical interventions. A recent report from the Centers for Disease Control and Prevention CDC working group on drug-resistant Streptococcus pneumoniae 20 , 22 includes an option for tympanocentesis versus empiric second-line antibiotic therapy in cases where initial antibiotic therapy has failed.
Few experiences are more self-educating than to diagnose acute otitis media by the history and ear examination and then encounter the absence of fluid on tympanocentesis. Although few family physicians are using this procedure in office practice, it is no more difficult than many other commonly performed office surgeries. The procedure has a satisfactory safety record. For example, with more than procedures performed in our office during the past 10 years, only four instances have occurred of minor complications drainage of fluid or blood in the middle ear , all of which resolved without intervention.
Proper restraint of the patient and excellent visualization of the tympanic membrane are essential when tympanocentesis is performed. Mild sedation may also be helpful in some cases. The average physician may examine the ears of more than 30 patients each working day, five days per week for about 40 weeks per year, for a total of more than 14, ears examined each year. Nevertheless, the medical literature suggests that acute otitis media is frequently over-diagnosed.
Good otoscopic illumination, cerumen removal and attention to the position and mobility of the tympanic membrane rather than only to the color are important for an accurate diagnosis.
Tympanometry or acoustic reflectometry can add information in some cases, and tympanocentesis remains the gold standard for diagnosis in selected difficult cases. Already a member or subscriber?
Log in. Interested in AAFP membership? Learn more. School of Medicine. Pichichero completed a pediatric residency at the University of Colorado School of Medicine, Denver, and fellowships in adult and pediatric allergy and immunology, and in pediatric infectious disease. Address correspondence to Michael E.
Pichichero, M. Reprints are not available from the author. Phenoxymethylpenicillin and therapeutic failure in acute otitis media. Scand J Infect Dis. Guideline: acute otitis media. Hayden GF. Acute suppurative otitis media in children. Diversity of clinical diagnostic criteria. Clin Pediatr [Phila]. Otitis Media Guideline Panel. Clinical practice guideline. Otitis media with effusion in young children. Rockville, Md. Lack of specific symptomatology in children with acute otitis media.
Pediatr Infect Dis J. Heikkinen T, Ruuskanen O. Signs and symptoms predicting acute otitis media. Arch Pediatr Adolesc Med. Acute otitis media: toward a more precise definition.
Pneumatic otoscopy and otitis media: the value of different tympanic membrane findings and their combinations. Recent advances in otitis media: proceedings of the fifth international symposium, May 20—24, Ft. Lauderdale, Fla. Louis: Decker, —5. Tympanometry and otoscopy prior to myringotomy: issues in diagnosis of otitis media. Int J Pediatr Otorhinolaryngol. Comparison of spectral gradient acoustic reflectometry and other diagnostic techniques for detection of middle ear effusion in children with middle ear disease.
Diagnostic value of acoustic reflectometry in children with acute otitis media. Adequate illumination for otoscopy.
Variations due to power source, bulb, and head and speculum design. Am J Dis Child. Assessment of otoscopists' accuracy regarding middle-ear effusion. The child's hearing is restored after the fluid is drained. The tubes usually fall out on their own after six to 12 months. Your child's surgeon may also recommend the removal of the adenoids lymph tissue located in the space above the soft roof of the mouth, also called the nasopharynx if they are infected.
Removal of the adenoids has shown to help some children with otitis media. Treatment will depend on the type of otitis media. Consult your child's health care provider regarding treatment options. In addition to the symptoms of an ear infection listed above, untreated ear infections can result in any or all of the following:.
Our pediatric otolaryngologists are committed to providing compassionate and comprehensive care for children with ear, nose, and throat conditions. As part of the Johns Hopkins Children's Center, you have access to all the specialized resources of a children's hospital.
Your child will also benefit from experts who use advanced techniques to treat both common and rare conditions. Health Home Conditions and Diseases. Facts about otitis media About 3 out of 4 children have at least one episode of otitis media by the time they are 3 years of age. Who is at risk for getting ear infections?
While any child may develop an ear infection, the following are some of the factors that may increase your child's risk of developing ear infections: Being around someone who smokes Family history of ear infections A weak immune system Spends time in a daycare setting Absence of breastfeeding Having a cold Bottle-fed while lying on his or her back What causes ear infections? The following are some of the reasons that the eustachian tube may not work properly: A cold or allergy which can lead to swelling and congestion of the lining of the nose, throat, and eustachian tube this swelling prevents the normal drainage of fluids from the ear A malformation of the eustachian tube What are the different types of otitis media?
Different types of otitis media include the following: Acute otitis media. Ear Infection Symptoms The following are the most common symptoms of otitis media. Symptoms may include: Unusual irritability Difficulty sleeping or staying asleep Tugging or pulling at one or both ears Fever, especially in infants and younger children Fluid draining from ear s Loss of balance Hearing difficulties Ear pain The symptoms of otitis media may resemble other conditions or medical problems.
How is otitis media diagnosed? A hearing test may be performed for children who have frequent ear infections. Management of acute otitis media: update. Otitis media with effusion. Pelton SI. Otoscopy for the diagnosis of otitis media.
The predictive value of tympanometry in the diagnosis of middle ear effusion. Clin Otolayngol Allied Sci. Kimball S. Acoustic reflectometry: spectral gradient analysis for improved detection of middle ear effusion in children.
American Academy of Pediatrics. The assessment and management of acute pain in infants, children, and adolescents. A randomized, double-blind, multi-centre controlled trial of ibuprofen versus acetaminophen and placebo for symptoms of acute otitis media in children. Fundam Clin Pharmacol. Efficacy of Auralgan for treating ear pain in children with acute otitis media. Arch Pediatr Adolesc Med. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial.
Delayed prescription may reduce the use of antibiotics for acute otitis media: a prospective observational study in primary care. American Academy of Family Physicians. Choosing Wisely. Otitis media. Accessed September 24, Siwek J, Lin KW. Choosing Wisely: more good clinical recommendations to improve health care quality and reduce harm.
Am Fam Physician. Treatment of otitis media with observation and a safety-net antibiotic prescription. Bacteriologic and clinical efficacy of high dose amoxicillin for therapy of acute otitis media in children. Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol. A multicenter, open label, double tympanocentesis study of high dose cefdinir in children with acute otitis media at high risk of persistent or recurrent infection.
High-dose azithromycin versus high-dose amoxicillin-clavulanate for treatment of children with recurrent or persistent acute otitis media. Prevalence of antimicrobial resistance among respiratory tract isolates of Streptococcus pneumoniae in North America: results from the SENTRY antimicrobial surveillance program.
Single-dose intramuscular ceftriaxone for acute otitis media in children. Bacteriologic and clinical efficacy of one day vs. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Hearing thresholds and tympanic membrane sequelae in children managed medically or surgically for otitis media with effusion [published correction appears in Arch Pediatr Adolesc Med. Pacifier as a risk factor for acute otitis media: a randomized, controlled trial of parental counseling.
Passive smoking and middle ear effusion among children in day care. Impact of the pneumococcal conjugate vaccine on otitis media [published correction appears in Pediatr Infect Dis J. Xylitol for preventing acute otitis media in children up to 12 years of age.
The role of prebiotics and probiotics in prevention and treatment of childhood infectious diseases. Management of eustachian tube dysfunction with nasal steroid spray: a prospective, randomized, placebo-controlled trial. Arch Otolaryngol Head Neck Surg. Clinical practice guideline: tympanostomy tubes in children.
Otolaryngol Head Neck Surg. Otitis media in infants aged 0—8 weeks: frequency of associated serious bacterial disease. Pediatr Emerg Care. Acute otitis media in infants younger than two months of age: microbiology, clinical presentation and therapeutic approach.
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Contact afpserv aafp. Want to use this article elsewhere? Get Permissions. Read the Issue. Sign Up Now. Next: Dermoscopy for the Family Physician. Oct 1, Issue. Otitis Media: Diagnosis and Treatment. This is a corrected version of the article that appeared in print.
Author disclosure: No relevant financial affiliations. C 8 Middle ear effusion can be detected with the combined use of otoscopy, pneumatic otoscopy, and tympanometry.
C 9 Adequate analgesia is recommended for all children with AOM. C 8 , 15 Deferring antibiotic therapy for lower-risk children with AOM should be considered. C 19 , 20 , 23 High-dose amoxicillin 80 to 90 mg per kg per day in two divided doses is the first choice for initial antibiotic therapy in children with AOM.
C 8 , 10 Children with middle ear effusion and anatomic damage or evidence of hearing loss or language delay should be referred to an otolaryngologist. Enlarge Print Table 1. Risk Factors for Acute Otitis Media Age younger Allergies Craniofacial abnormalities Exposure to environmental smoke or other respiratory irritants Exposure to group day care Family history of recurrent acute otitis media Gastroesophageal reflux Immunodeficiency No breastfeeding Pacifier use Upper respiratory tract infections Information from references 8 and 9.
Table 1.
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