Acute Otitis Media

You may be rolling your eyes right now at the thought of reading about AOM. Certainly it is not as exciting to think about as Hirschsprung’s Enterocolitis and we see it so often there certainly can’t be anything new to learn. Well, sometimes it is important to re-learn basics as well (at least for myself this is true). In addition, AOM is the #1 reason antibiotics are prescribed to children in the USA… so we need to know it well.

  • The problem: clinical history is a poor predictor of AOM, visualization of the TM can be difficult, and redness doesn’t always equate with inflammation. Inaccurate diagnosis leads to inappropriate use of antibiotics and all the potential problems that entails.


  • The most important aspect of AOM is making the diagnosis accurately (you need 3 elements)
    • Acute Onset of Symptoms
    • Signs of Middle Ear Effusion
      • Buldging TM, poor mobility, otorrhea, or air-fluid level
    • Signs of Middle Ear Inflammation
      • TM erythema or otalgia (that interferes with nl activity)


  • A trick or two to help your examination:
    • Distract the child (Child Life and Bubbles often distract even me)
    • Teach the guardian how to safely restrain the child
    • Remove the cerumen!
      • Wet a small cotton-tip applicator with an alcohol swab
      • Irrigate or use colace when necessary
      • Have patience!
    • Acoustic Reflectometry – use sound waves to determine the presence of middle ear effusion


  • Treat Appropriately
    • Most important therapy = PAIN Medications!
    • It’s an infection… so antibiotics are needed right? Well….
      • Many (including the AAP) advocate for an observation without antibiotics for those pts 6months – 2 yrs with UNcertain diagnosis or for those >2yrs with non-severe illness (severe = severe otalgia or fever ≥ 39°C).
      • Recent literature (Hoberman, NEJM 2011) states that children 6 months to 23 months diagnosed with an AOM do “better” (shorter duration of symptoms and less treatment failures – and more diarrhea and diaper rash) when treated with antibiotics.
      • Again, what is important is accurately diagnosing the condition in the beginning.
      • If the decision is made to observe without antibiotic therapy, the parents can be given a prescription for Abx with instructions to fill it if the child does not improve in 48 to 72 hours, or see the PMD in 2 days. Follow-up is very important if no antibiotics are given.


Spiro, D. Tay, K. Wait-to-see prescription for the treatment of acute otitis media. JAMA 2006, 1235.
Rosenfeld RM, Kay D. Natural history of untreated otitis media. In: Rosenfeld RM, Bluestone CD, eds. Evidence-Based Otitis Media. 2nd ed. Hamilton, ON, Canada: BC Decker Inc; 2003:180-198.
Little P, Gould C. Williamson I, Moore M, Warner G, Dunleavey J. Pragmatic randomized controlled trial of two prescribing strategies for childhood acute otitis media. BMJ. 2001; 322:336-342.
American Academy of Pediatrics and American Academy of Family Physicians. Diagnosis and management of acute otitis media. Pediatrics 2004; 113: 1451-65.
Hoberman, A. et al. Treatment of acute otitis media in children Under 2 years of age. N Engl J Med 2011; 364:105-115.
Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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  1. […] This little Morsel stems from a intellectually fun conversation with Dr. Modisett (for those of you overseas, Dr. Modisett is one of our brilliant and illustrious Chief Residents at Carolinas – yes, I am spoiled).  This is another great reason to discuss not throwing antibiotics at every kid with an ear. […]

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