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  • Otitis media is an inflammation of the middle ear that is most common in infants and children. There are three subtypes of otitis media: acute otitis media, otitis media with effusion, and chronic otitis media. The three are differentiated by (a) acute signs of infection, (b) evidence of middle ear inflammation, and (c) presence of fluid in the middle ear.


  • Bacteria have been found in more than 90% of cases of otitis media. Common bacterial pathogens include Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis.

  • Acute otitis media usually follows a viral upper respiratory tract infection that impairs the mucociliary apparatus and causes eustachian tube dysfunction in the middle ear.

  • Many S. pneumoniae isolates in the United States are penicillin nonsusceptible, and most nonsusceptible strains have high-level penicillin resistance.

  • Many H. influenzae isolates and nearly all M. catarrhalis isolates, from the upper respiratory tract, produce β-lactamases.

Clinical Presentation

  • Acute otitis media is characterized as acute onset of otalgia (ear pain). Irritability and tugging on the ear are often the first clues that a child has acute otitis media.

  • Children should be diagnosed with acute otitis media if they have middle ear effusion and either (1) moderate-to-severe bulging of the tympanic membrane or new onset otorrhea not due to acute otitis externa or (2) mild bulging of the tympanic membrane and onset of ear pain within the last 48 hours or intense erythema of the tympanic membrane.

  • Nonverbal children with ear pain might hold, rub, or tug their ear. Very young children might cry, be irritable, and have difficulty sleeping. Signs and symptoms include bulging of the tympanic membrane, otorrhea, otalgia (considered to be moderate or severe if pain lasts at least 48 hours), and fever (considered to be severe if temperature is 39°C [102.2°F] or higher).


  • Goals of Treatment: Pain management, prudent antibiotic use, and secondary disease prevention. Acute otitis media should first be differentiated from otitis media with effusion or chronic otitis media.

  • Primary prevention of acute otitis media with pneumococcal conjugate vaccine and annual influenza vaccine are recommended for all children.

  • Pain of otitis media should be addressed with oral analgesics. Acetaminophen or a nonsteroidal anti-inflammatory agent, such as ibuprofen, should be offered early to relieve pain of acute otitis media.

  • Children 6 months–12 years of age, with moderate-to-severe ear pain or temperature of 39°C (102.2°F) or higher should receive antibiotics. Children 6–23 months of age, with nonsevere bilateral acute otitis media should also receive antibiotics. Children 6–23 months, with nonsevere unilateral acute otitis media, and children 24 months–12 years of age, with nonsevere acute otitis media, may receive initial antibiotics or initial observation without antibiotics.

  • The central principle is to administer antibiotics quickly when the diagnosis is certain, but to withhold antibiotics, at least initially, ...

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