Chapter VI.6. Otitis Media and Otitis Externa
Amanda Chau
Vince K. Yamashiroya, MD
August 2022

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A parent brings her 2 year old son to your office because of a chief complaint of fussiness and tugging at his right ear for the past two days. He has had coughing and a runny nose for about 5 days that has been treated with saline nose sprays and a humidifier. He has had a fever of about 101 degrees F (38.3 degrees C) axillary for the past two days. Both parents smoke cigarettes. He attends daycare. His past medical history is significant for ear infections in the past, with his last otitis media episode 5 months ago, treated with amoxicillin. His immunizations are up to date, including the 13-valent pneumococcal conjugate vaccine.

Exam: VS T 38.4, P 100, RR 28, BP 100/65. He is active, alert to his surroundings and otherwise in no distress. HEENT exam: Right tympanic membrane is erythematous and bulging, with poor mobility on pneumatic otoscopy. Left TM is translucent, pearly sheen, with good mobility. Throat is non-erythematous. There are small cervical lymph nodes. Lungs are clear to auscultation. The rest of the examination is normal.

He is diagnosed with acute right otitis media. He is prescribed amoxicillin and acetaminophen. His parent is told to follow up in 2 to 3 days if he is not better and warned against the dangers of their child’s exposure to second hand cigarette smoke.

Otitis media (OM), or an acute infection of the middle ear, is one of the most common diagnoses that pediatricians encounter and remains the most common condition for pediatric antibiotic use in the United States. It is estimated that otitis media affects nearly 25% of all children within the first year of life. At least 60% of all children are affected by OM by age 5, with roughly 15% experiencing one of the more serious forms, such as recurrent or chronic OM (1,2). This chapter will focus on two types of otitis media, namely acute otitis media (AOM) and otitis media with effusion (OME).

The middle ear is a gas filled cavity in the petrous part of the temporal bone between the external auditory canal and the inner ear. It contains three ossicles called the malleus, incus, and stapes. These ossicles conduct sound from the tympanic membrane to the inner ear. Factors hindering the movement of these ossicles, such as pus or fluid in the middle ear, will adversely affect hearing. The middle ear is connected to the nasopharynx by the eustachian tube. The eustachian tube allows for ventilation and clearance of fluid from the middle ear. The tympanic membrane (TM) or eardrum is normally slightly convex, translucent, and mobile. When there is an ear infection, the middle ear becomes fluid filled, sometimes with pus. There is subsequent bulging of the TM with yellow, opaque, or red discoloration, as well as reduced mobility (3).

Otitis media is common in infants and young children with the peak age being between 6 to 18 months of age (4). This is due to anatomical and immunologic factors since these children still lack many protective antibodies against viral and bacterial organisms. The most important risk factor for AOM is age. The incidence of OM decreases after the first year of life and then increases again when the child enters school. It becomes less common after 7 years of age. Other factors that increase the risk for OM are attendance in day care, second hand cigarette smoke exposure, craniofacial abnormalities such as cleft palate, immunologic deficiencies, family history, ethnicity (Native Americans, Alaskan, and Canadian Eskimos, and indigenous Australians are at higher risk for complicated and recurrent OM), and a slight increase with pacifier use. Conversely, a protective factor against AOM is breastfeeding. This may be due to immune factors (e.g., secretory IgA and IgG), non-immune factors (e.g., interferon, glycoproteins, lactadherin), and anti-inflammatory factors (e.g., antioxidants, TNF-alpha, lactoferrin). Also, babies are breastfed while in a vertical or semi-reclining position, whereas babies who are bottle fed tend to be in a supine position. The practice of bottle feeding in the supine position (e.g., bottle propping) is thought to increase OM by reflux of fluids from the nasopharynx into the middle ear via the eustachian tube (5,6).

For decades, it has been well established that the three main organisms causing OM are Streptococcus pneumoniae, non-typable Haemophilus influenzae, and Moraxella catarrhalis. However, since the widespread use of the 13-valent pneumococcal conjugate vaccine (Prevnar-13), the relative proportions of each cause has changed. While the incidence of OM caused by S. pneumoniae has declined, incidence of OM caused by H. influenzae and M. catarrhalis has risen (7). Other less common organisms are Streptococcus pyogenes, Staphylococcus aureus, and anaerobes (8). AOM caused by gram negative enteric bacteria such as Escherichia coli can occur in young infants in the first few months of life (5).

The diagnosis of otitis media is a challenging one for pediatricians because of difficulty obtaining an adequate examination of the tympanic membrane (TM). The presence of cerumen and uncooperative and frightened patients complicate this. A common symptom of OM is otalgia, but otorrhea and hearing loss can also occur. Infants may only manifest otalgia by fussiness in the presence of fever. Other less common symptoms of OM and its complications are vertigo, nystagmus (unidirectional, horizontal, jerk type), tinnitus, swelling in the posterior auricular area (associated with mastoiditis), facial paralysis (due to disease within the temporal bone), and purulent conjunctivitis (which is associated with non-typable H. influenzae).

The best tool for the diagnosis of OM is the pneumatic otoscope. Inspection of the TM should include four characteristics: position, color, degree of translucency, and mobility. Also, by visualizing the TM, one notices several landmarks such as the malleus which is divided into the short process, manubrium, and umbo; the long process of the incus; and the pars flaccida on the superior aspect and the pars tensa on the inferior aspect (8). It should be noted that a tympanic membrane might become red in a crying child, although at least one study has demonstrated that this does not occur (9). Other methods of diagnosing OM include tympanometry, tympanocentesis, and acoustic reflectometry; however, these are not routinely utilized in cases of AOM (3).

AOM typically presents as a relatively sudden onset of otalgia, fever, and hearing loss, which are preceded by an upper respiratory tract infection lasting for several days. Fever occurs in about 30 to 50% of patients of AOM and is usually < 40 degrees C. Fever >40 degrees C suggests bacteremia or a different etiology of the fever (10). Pneumatic otoscopy reveals an opaque TM that is bulging with poor mobility. Erythema is a characteristic finding, but it may be absent. There may be perforation.

OME, on the other hand, is asymptomatic in most children. Some may complain of hearing loss and less commonly tinnitus and vertigo. In younger children, there may be speech and language delay; or it may be picked up after a failed hearing screen at school or during a well child checkup (11). Older children may complain of a persistent or intermittent sensation of a pressure change in their ears. The TM commonly appears opaque but may be retracted or full. An air fluid level or bubbles can sometimes be seen. Mobility can also be decreased.

It is important to clearly differentiate AOM from cases of OME because the management of each is different, but this is often not easily done. Some key points would be that fever, irritability, redness, otalgia, and a bulging and opaque eardrum are associated with AOM, whereas absence of symptoms except for hearing loss, and a retracted eardrum are associated with OME. Both AOM and OME can present with middle ear effusion and decreased mobility of the TM. The middle ear effusion is not an infectious process and will not benefit from antibiotic therapy (7). Effusion can persist after treatment of otitis media and should not be considered an antibiotic failure. As much as 50% of children will have OME at one month following an episode of AOM. Administration of additional antibiotic therapy in this setting facilitates the emergence of antibiotic-resistant strains of bacteria and increases the risks of antibiotic side effects (10).

The need for antibiotic therapy for AOM should be decided on the presence of a bulging, opacified and inflamed tympanic membrane (tympanitis) with loss of mobility and evidence of an effusion. Once the diagnosis of otitis media has been established, the main goals of treatment are to control pain and to monitor and treat the infection with observation or antibiotic therapy. If severe otalgia is present, then analgesia becomes a major therapeutic consideration. Minor pain can be treated with acetaminophen or ibuprofen in most instances. For more severe pain, acetaminophen and ibuprofen can be given together, along with topical anesthetics with lidocaine or a similar local anesthetic (12). Over the counter ear pain drops containing benzocaine were frequently utilized for analgesia, but these were removed market by the FDA in 2018 due to risk of methemoglobinemia.

The acute signs and symptoms of AOM usually resolves within three days despite whether the infection is treated with antibiotics or not. However, treatment of AOM with antibiotics has been demonstrated to provide faster symptom relief. It is important to keep in mind that the absolute benefits of treating AOM with antibiotics are modest and that antibiotic related side effects are common (e.g., diarrhea, rash). Thus, some families may reasonably choose initial observation over antibiotic therapy (see Table 1 below for criteria). Consideration of the use of analgesics is recommended regardless of whether antibiotic therapy is prescribed.

If the decision is made not to administer antibiotics but to observe instead, then an observational approach can be used in which the caregiver is given a paper prescription for antibiotics, and to use it if the child is not better in 48 to 72 hours. Alternatively, if the caregiver is not given a prescription for antibiotics, the caregiver can call or follow up with doctor if the child is not better in 48 to 72 hours to receive antibiotic treatment. Observation without antibiotics is an option that is dependent on age, severity, caregiver preference, and assurance of follow up. If the observational approach is chosen, caregivers must first understand the risks and benefits and the importance of initiating appropriate follow up if symptoms worsen or persist after 48 to 72 hours (10).

Table 1: Recommendations for initial management of uncomplicated AOM provided by the American Academy of Pediatrics (AAP)
AOM with Otorrhea
AOM (unilateral or bilateral) with Severe Symptoms*
Bilateral AOM Without Otorrhea
Unilateral AOM Without Otorrhea
6mo – 2y
Oral antibiotic therapyOral antibiotic therapyOral antibiotic therapyOral antibiotic therapy OR observation
≥ 2y
Oral antibiotic therapyOral antibiotic therapyOral antibiotic therapy OR observationOral antibiotic therapy OR observation
*Severe symptoms are defined as moderate to severe otalgia, or otalgia for > 48 hours, or fever >39 degrees C (102.2 degrees F), or if there is uncertain access to follow-up after the visit. Non-severe symptoms are defined as mild otalgia <48hrs, with fever < 39 degrees C (102.2 degrees F) (7,13).

Generally, current guidance recommends clinicians to consider oral antibiotics as first-line treatment in AOM with or without otorrhea. Although the opening in the eardrum of patients with otorrhea from a torn or perforated eardrum should allow for topical antibiotics to reach the middle ear directly, evidence on the effectiveness of this approach in pediatrics is lacking (13,14).

The choice of oral antibiotic is dependent on efficacy, palatability, side effects, convenience of dosing, drug allergies, resistance patterns in the community, and cost. The drug of choice for treating AOM remains amoxicillin, although bacterial resistance continues to be a problem. For this reason, it is recommended that the dose of amoxicillin be increased from 40 to 50 mg/kg/day to 80-90 mg/kg/day in two divided doses, up to a maximum of 3 grams per day as data has demonstrated that S. pneumoniae isolates have remained susceptible to this drug 83% to 87% of the time. Amoxicillin should be given if the child has not received it in the past 30 days, does not have concurrent purulent conjunctivitis, and is not allergic to amoxicillin (or other penicillins). If there is concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome), an antibiotic with more beta lactamase coverage such as amoxicillin and clavulanate should be used to expand coverage for organisms such as H. influenzae (7).

For those with a penicillin allergy, antibiotic selection depends on whether the reaction was immediate (e.g., hives or anaphylaxis) or delayed (e.g., rash). For those with an immediate reaction, choices are macrolide or lincosamide antibiotics such as azithromycin and clindamycin. However, one should keep in mind that resistance is common with these antibiotics to S. pneumoniae, and they are not effective against H. influenzae (10). For delayed allergic reactions, antibiotic choices are cefdinir, cefpodoxime, and cefuroxime. If unable to take oral medications, an alternative is one intramuscular dose of ceftriaxone at 50 mg/kg or IV per day for 1 to 3 days (7).

Upon initiating antibiotic therapy for AOM, there should be clinical improvement in 48 to 72 hours. If not, treatment failure must be considered with treatment changed to second line therapy (8,13). The AAP guideline recommends amoxicillin-clavulanate (with the amoxicillin component of 80-90 mg/kg/day) or ceftriaxone (50 mg/kg IM or IV per day for 3 days) be used as second line therapy. If there is failure with second-line therapy, then the third line therapy is clindamycin (30-40 mg/kg/day in 3 divided doses) with a third generation cephalosporin, or tympanocentesis with a culture taken. If the culture shows multidrug resistant bacteria, a consultation with an infectious disease specialist should be obtained (7,13). The optimal duration of treatment is not known, but generally is 10 days, especially in children less than 2 years of age or any age with severe symptoms. However, shorter courses can be used for older children with mild to moderate symptoms. For those between 2 to 6 years of age, a 7 day course of oral antibiotics can be used, and those over 6 years of age, a 5 to 7 day course is appropriate. An exception is intramuscular ceftriaxone which is given for 1 to 3 days (7,13).

A follow up visit is recommended if the child does not improve in 48 to 72 hours (possible treatment failure) or when symptoms resolve, a reexamination should be done in 8 to 12 weeks for children younger than age 2 years and for children older than age 2 with language or learning problems, since that is when 80%-90% of middle ear effusion should be resolved (10). In children with acute otitis media with tympanostomy tubes with or without chronic suppurative otitis media, quinolone otic drops such as ofloxacin or ciprofloxacin can be used for well-appearing children over age 2 years (10).

Not only do we treat otitis media for symptomatic relief, but also to prevent its complications. The complications of OM include conductive and sensorineural hearing loss, mastoiditis, cholesteatoma, labyrinthitis, facial paralysis, meningitis, brain abscess, and lateral sinus thrombosis (5). Fortunately, because we live in the antibiotic and vaccine era, these complications are rarely seen. Hence, the prognosis for otitis media is excellent. In most children, otitis media resolves after antibiotic therapy. Only in a few children does medical therapy fail, and more aggressive measures are needed, such as myringotomy and tympanostomy tubes (7).

While otitis media is often associated with fever, it does not necessarily cause the fever. In the evaluation of patients who present with fever and are found to have OM on exam, it cannot be concluded with certainty that the etiology of the fever has been confirmed. The patient could still have an alternative diagnosis as the cause of the fever such as influenza, pneumonia, COVID-19, urinary tract infection, streptococcal pharyngitis, etc. Whether OM causes fever can be answered by observations. OM is known to occur with concurrent respiratory viruses and perhaps the fever is caused by these viruses and not the OM itself. In large studies on OM, roughly half the study cohort has fever. Otitis media and fever do not meet the dose-response relationship criterion for cause and effect. In other words, high fever is often associated with mild severity of otitis media and low or no fever is often associated with high severity of otitis media. The middle ear cavity is very small and even if the middle ear effusion is purulent fluid, an abscess of this size typically does not cause fever in most other parts of the body. These clinical observations support the standard clinical practice that in the urinary tract infection clinical decision rules and the neonatal fever clinical decision rules, the presence of otitis media does not count as a definitive etiologic cause for the presenting fever.

There are times that a child may need to be referred to an otolaryngologist to have placement of a tympanostomy tube, also known as a pressure equalization (PE) tube. Indications for this would be if a child is considered to have recurrent ear infections, which are defined as having 3 AOM infections in 6 months or 4 AOM infections in 1 year. This is especially important in young children since recurrent and chronic ear infections can affect hearing, which would then have an impact on speech development (10). The most recent 2013 AAP guidelines describe the need for tympanostomy tubes as an option, since there are risks involved with surgery such as anesthesia with potential long-term complications such as tympanosclerosis, focal atrophy, retraction pockets, and chronic perforation. It should be noted that long-term, low-dose antibiotic prophylaxis is strongly discouraged due to the possibility of antibiotic resistance and side effects of taking the medications, with the benefit of long-term antibiotic use being modest (13).

After tympanostomy tube placement, one of the problems that can occur is otorrhea. One needs to determine if it is acute (less than 6 to 8 weeks) or chronic (over 6 to 8 weeks). The causes of acute otorrhea are either due to acute otitis media or contaminated water entering the middle ear. The organisms involved in AOM with PE tubes are the same as those without PE tubes, namely S. pneumoniae, M. catarrhalis, and non-typeable H. influenzae for patients <2 years of age. For otorrhea in older children who may have contaminated water entering the middle ear or those having AOM not improved with oral antibiotics, the organisms are the same as otitis externa, which include Pseudomonas and S. aureus. Therefore, the choice of medication is dependent on the age of the child and whether there are systemic symptoms or cellulitis. For infants and children without systemic symptoms or cellulitis, topical treatment such as fluoroquinolones can be used. For children with systemic symptoms or severe ear symptoms such as copious ear discharge or ear pain, high dose amoxicillin (80 to 90 mg/kg) or amoxicillin-clavulanate can be used. If oral antibiotics are not working after 5 days, antibiotic ear drops effective against P. aeruginosa and S. aureus should be given. If cellulitis is present, the child should be treated with both oral antibiotics against S. aureus and S. pneumoniae, and topical antibiotics with a culture of the discharge taken. Because acute otorrhea after PE tube placement can be caused by contaminated water entering the middle ear, ear plugs can be used to prevent this during water activities, although there is a lack of consensus among otolaryngologists regarding water precautions. Therefore, the parents need to discuss water precautions and the need for ear plugs with their specialist (15).

Chronic otorrhea after tympanostomy tube placement is usually due to inadequate treatment of an acute cause of otorrhea such as debris in the ear canal. This can be remedied by suctioning the debris and using a corticosteroid-antibiotic ear drop for 5 to 7 days. One of the problems with chronic use of antibiotic ear drops may be the emergence of unusual pathogens such as Aspergillus, Actinomyces, and Candida albicans. Granulation tissue and cholesteatoma could also cause chronic otorrhea. Therefore, any chronic otorrhea should be referred to an otolaryngologist (15).

The length of time that tympanostomy tubes remain in place depends on the type of tube placed. Short-term tubes are most commonly placed and last for 6 to 18 months. Long term tubes last for over 15 months and are used less frequently due to complications such as higher risk of otorrhea and persistent perforation of the eardrum. Tubes normally extrude out of the TM spontaneously and naturally come out of the ear canal with time. Occasionally, ear tubes can be retained and need to be removed surgically depending on the type of tube it is. For a short term tube, the time for removal is 2 to 3 years, and a time for removal of a long term tube is over 3 years. Failure to remove a tube at this time could increase the rate of a persistent TM perforation (16).

Otitis externa (OE) is another common pediatric diagnosis. Several factors can predispose patients to develop OE. Swimming is one of the most common risk factors, which is why OE is sometimes called swimmer’s ear. The risk of developing OE in a swimmer is increased by five times compared to those who do not swim. Other risk factors include dryness (e.g., lack of cerumen and dry ear skin), other skin diseases (e.g., dermatitis, previous infection), and trauma (e.g., using cotton tipped applicators, earplugs, or hearing aids) (7,17).

The pathophysiology of OE is the following: As the humidity in the outer ear increases, the stratum corneum in the cartilaginous portion of the ear absorbs water, which results in edema. Edema blocks the pilosebaceous units in the ear, thereby decreasing the excretion of cerumen. A decrease in cerumen causes an increase in the pH of the external ear, in addition to reducing its water repelling covering. The exposed skin becomes susceptible to maceration and the higher pH becomes a favorable environment for bacteria such as Pseudomonas. Bacteria can then penetrate through the dermis after superficial breakdown or through minor trauma such as with cotton tipped applicators. Inflammation and infection result (7).

The most common organisms cultured in OE are Pseudomonas and S. aureus. Other bacterial organisms that can be cultured are Enterobacter aerogenes, Proteus mirabilis, Klebsiella pneumoniae, streptococci, coagulase-negative staphylococci, and diphtheroids. Fungal infection such as those caused by Aspergillus and Candida can rarely occur in patients, typically following treatment for bacterial OE (7).

Symptoms of OE initially include pruritus and aural fullness, which then progresses to ear pain that may be severe and out of proportion to its appearance. Purulent otorrhea and hearing loss from edema of the canal may be present as well. Examination shows an inflamed and erythematous ear canal, with variable involvement of the bony canal. Manipulation of the pinna and pressure on the tragus elicit pain. Although the tympanic membrane is not affected, it and the medial portion of the canal can become involved and often look granular. When this occurs, pneumatic otoscopy is needed to rule out concomitant otitis media. Tender and palpable lymph nodes may be present in the periauricular and preauricular areas (7,17).

Management of OE, like AOM, also involves antibiotics and pain control. Analgesics such as acetaminophen and ibuprofen can be used to treat mild to moderate pain. In general, first line treatment with fluoroquinolone eardrops (e.g., ofloxacin or ciprofloxacin) is well tolerated. Other common topical antibiotics include polymyxin B and neomycin combinations and aminoglycosides (e.g., tobramycin and gentamicin) (18). A new formulation of ciprofloxacin suspension has recently become available; it is liquid at cooler temperatures and thickens into a gel at body temperature. This allows a single application to work for multiple days and may be useful when there are compliance problems.

Many otic drops also contain corticosteroids to reduce inflammation and edema. If there is a lot of fluid drainage, it may be preferable to wick out most of the fluid prior to instilling the drops using the corner of a facial tissue rolled into a thin rod. If there is severe edema preventing effective instillation of drops, a wick can be placed into the membranous canal with otic drops applied several times a day onto the wick which can be replaced every 48 to 72 hours until the edema resolves. After 2 to 3 days, the edema of the ear canal is usually markedly improved. Cleaning the ear canal such as irrigating with 2% acetic acid to remove debris can be a useful adjunct to therapy (19).

Prevention may be necessary for those patients who suffer from recurrences. Dilute alcohol or acetic acid (2%) can be instilled immediately after swimming or bathing. A preparation of 50% white vinegar and 50% rubbing alcohol works well for this. Patients should protect their ears from water when bathing (by placing a cotton ball with petroleum jelly into the ear canal) and should avoid swimming until their OE resolves. Other preventative methods include wearing ear plugs, shaking the ears dry after swimming, and using a blow dryer (18).

1. What is the peak age of otitis media?
2. What are some risk factors for otitis media?
3. What is the best tool for diagnosing otitis media (not gold standard)?
4. What is the difference between acute otitis media and otitis media with effusion?
5. What are the three most common organisms that cause otitis media?
6. What antibiotic is the drug of choice against otitis media?
7. What are the two second-line antibiotics recommended by the AAP if amoxicillin fails and there is no amoxicillin allergy?
8. What antibiotics can be used to treat otitis media in a child who has had an immediate allergic reaction to amoxicillin in the past (for example, hives or anaphylaxis)?
9. What are some complications of otitis media?
10. What are the most common organisms cultured in otitis externa?
11. What are four factors that can predispose a patient to develop otitis externa?
12. What can be instilled in the ear to prevent otitis externa in an otitis externa prone child?
13. Per AAP/AAFP/CDC guidelines, would antibiotics be started in the patients below?
   a. 8 month old boy with URI symptoms, and slightly fussy. Has a fever of 38 degrees C which is controlled with acetaminophen. Right TM shows a full, moderately red TM with poor mobility.
   b. 5 year old girl with URI symptoms and slight right ear pain that is controlled with acetaminophen. Has a fever of 38 degrees C. Right TM shows a full, moderately red TM with poor mobility.
   c. 18 month old healthy boy seen for well-baby checkup. No fever, but has a little rhinorrhea for few days. Both TM’s are flat, dull, with poor mobility. Does not say any words on developmental screening.
14. When should a child be referred to an otolaryngologist for possible PE tube placement?

1. Meissner CH. Understanding otitis media in 2018. In: AAP News. 2018. Accessed April 1, 2022.
2. NIDCD publishes workshop report on otitis media and holds May advisory council meeting. 2021. Accessed April 1, 2022.
3. Wald ER. Acute otitis media in children: Clinical manifestations and diagnosis. In: Edwards MS, Isaacson MS (eds). UpToDate. 2020. Wolters Kluwer, Amsterdam. Accessed March 25, 2022.
4. Danishyar A, Ashurst JV. Acute Otitis Media. In: StatPearls. 2022. StatPearls Publishing, Treasure Island, FL. Accessed March 25, 2022.
5. Klein JO, Pelton S. Acute Otitis Media in Children: Epidemiology, microbiology, clinical manifestations, and complications. In: Kaplan SL, Isaacson MS (eds). UpToDate. 2020. Wolters Kluwer, Amsterdam. Accessed March 25, 2022.
6. Schanler RJ. Infant benefits of breastfeeding. In: Abrams SA (ed). UpToDate. 2021. Wolters Kluwer, Amsterdam. Accessed April 3, 2022.
7. Yoon PJ, Scholes MA, Herrmann BW. Chapter 18. Ear, Nose, & Throat. In: Hay Jr. WW, Levin MJ, Abzug MJ, Bunik M (eds). Current Diagnosis & Treatment: Pediatrics, 25th edition. 2020. McGraw Hill , New York, online version pp:1-19.
8. Kerschner JE, Preciado D. Chapter 658. Otitis Media. In: Kliegman RM, St. Geme JW, Blum NJ, et al (eds). Nelson Textbook of Pediatrics, 21st edition. 2020, Elsevier, Philadelphia, PA. pp: 3418-3431.
9. Yamamoto LG, Sumida RN, Yano SS, Derauf DC, et al. Does crying turn tympanic membrandes red? Clin Pediatr (Phila). 2005;44(8):693-697.
10.Klein JO, Pelton S. Acute Otitis Media in Children: Treatment. In: Edwards MS, Isaacson MS (eds). UpToDate. 2020. Wolters Kluwer, Amsterdam:. Accessed March 25, 2022.
11. Pelton SI, Marom T. Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis. In: Kaplan SL, Isaacson GC (eds). UpToDate. 2021. Wolters Kluwer, Amsterdam. Accessed March 29, 2022.
12. Klein JO, Pelton S. Acute Otitis Media in Children: Treatment. In: Edwards MS, Isaacson MS (eds). UpToDate. 2020. Wolters Kluwer, Amsterdam. Accessed March 25, 2022.
13. Lieberthal, AS, Carroll, AE, Chonmaitree, T. The diagnosis and management of acute otitis media. Pediatrics. 2013;131:e964-e999. Accessed March 25, 2022.
14. Hullegie S, Venekamp RP, van Dongen TMA, et al. Topical or oral antibiotics for children with acute otitis media presenting with ear discharge: study protocol of a randomised controlled non-inferiority trial. BMJ Open. 2021;11(12):e052128. doi:10.1136/bmjopen-2021-052128.
15. Isaacson, GC. Tympanostomy tube otorrhea in children: Causes, prevention, and management. In: Messner AH, Kaplan SL (ed). UpToDate. 2022. Wolters Kluwer, Amsterdam. Accessed March 5, 2022.
16. Pelton SI, Marchisio P. Acute otitis media in children: Prevention of recurrence. In: Kaplan SL, Isaacson GC (eds). UpToDate. 2021. Wolters Kluwer, Amsterdam. Accessed March 29, 2022.
17. Goguen LA. External otitis: Pathogenesis, clinical features, and diagnosis. In: Deschler DG, Edwards MS (eds). UpToDate. 2020. Wolters Kluwer, Amsterdam. Accessed March 29, 2022.
18. Goguen LA. External otitis: Treatment. In: Deschler DG, Edwards MS (eds). UpToDate. 2020. Wolters Kluwer, Amsterdam. Accessed March 29, 2022.
19. Riviello RJ. Chapter 63. Otolaryngologic Procedures. In: Roberts JR, Custalow CB, Thomsen TW (eds). Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care, 7th edition. 2019. Elsevier, Philadelphia, PA. pp: 1338-1383.

Answers to questions
1. 6 to 18 months of age.
2. Age (6 to 18 months of age), attendance in daycare, second hand cigarette smoke exposure, craniofacial abnormalities, bottle feeding in the horizontal position, family history, ethnicity (Native Americans, Alaskan and Canadian Eskimos, indigenous Australians), and a slight increase with pacifier use.
3. Pneumatic otoscopy is the best diagnostic tool. Myringotomy/tympanocentesis is the gold standard, but not the best diagnostic tool because of its invasiveness.
4. AOM: otalgia, fever, hearing loss, associated with upper respiratory tract infection; TM that is opaque or erythematous and bulging with poor mobility, perforation. OME: commonly asymptomatic but may have hearing loss; retracted TM (but could be full).
5. Streptococcus pneumoniae, non-typable Haemophilus influenzae, Moraxella catarrhalis.
6. Amoxicillin
7. Amoxicillin-clavulanic acid or intramuscular ceftriaxone
8. Azithromycin and clindamycin. (Clarithromycin, erythromycin-sulfisoxazole can also be used, but these two choices were not mentioned in the chapter). One should keep in mind that there can be resistance to these antibiotics for S. pneumoniae, and that these antibiotics will not be effective against H. influenzae.
9. Conductive and sensorineural hearing loss, mastoiditis, cholesteatoma, labyrinthitis, facial paralysis, meningitis, brain abscess, and lateral sinus thrombosis.
10. Pseudomonas aeruginosa and Staphylococcus aureus.
11. Excessive wetness, lack of cerumen, preexisting skin problems, and trauma.
12. 2% acetic acid or dilute alcohol (i.e., white vinegar and rubbing alcohol mixture).
13.a. Yes. This patient is between 6 months to 2 years of age with a certain diagnosis. Antibiotics should be started regardless of disease severity.
13.b. No. This patient is over 2 years of age with a certain diagnosis, but does not have severe illness. Pain is controlled with medications. If one chooses not to treat with antibiotics, follow up is needed if there is no improvement in 48 to 72 hours, at which time antibiotics should be started. If follow up is not ensured, patient should be started on antibiotics.
13.c. Yes and no. This patient likely has OME and not AOM. Although antibiotics have not been demonstrated to be effective, a single course of antibiotics for 10 to 14 days may be used if tympanostomy tubes are required, especially if there is conductive hearing loss with speech delay. Due to developmental delay, this patient should be referred to early intervention and a formal audiological evaluation should be done.
14. If the child has 3 AOM in previous 6 month period, or 4 AOM in previous 12 month period.

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