Case Challenge: Acute Otitis Media in Children--Best Management Strategies

Gordon H. Sun, MD, MS


March 28, 2018

Signs and Symptoms of AOM

The 2013 AAP clinical practice guideline for the management of AOM[1] lists several scenarios in which AOM should or should not be diagnosed. AOM should be diagnosed in the following instances:

  • Moderate to severe bulging of the tympanic membrane or new-onset otorrhea not due to acute otitis externa; or

  • Mild bulging of the tympanic membrane and recent-onset (<48 hours) otalgia or intense erythema of the tympanic membrane.

The guideline also recommends that AOM not be diagnosed in patients who do not have middle ear effusion (MEE) based on pneumatic otoscopy and/or tympanometry. Although hearing loss may be present in patients with MEE, hearing loss is not required for the diagnosis of AOM.

Wait or Medicate?

A 5-year-old girl was brought by her parent to her pediatrician with a left-sided earache since the previous day. The parents have not observed any otorrhea, hearing loss, or fever. The patient's brother had begun coughing and sneezing a few days ago. The patient had no known medical or surgical history. She had not received any recent antibiotic therapy and was not currently taking medications. She had no known drug allergies.

The patient was afebrile (temperature, 37.1˚C) with normal pulse, respiratory rate, blood pressure, and oxygen saturation. She was wide awake and fidgety, and she exhibited no obvious discomfort during the ear exam. The left auricle, mastoid, and external auditory canal were all normal in appearance. The tympanic membrane was intact but mildly bulging, inflamed, and somewhat decreased in mobility. Right ear otoscopy was normal, as was the rest of the physical exam.


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