Pediatric emergency medicine trisk 1126 1126
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AOM is the most common illness prompting office visits and antimicrobial
prescriptions in childhood. Clinical practice guidelines have encouraged a stricter
diagnostic threshold for AOM, and immunization with PCV7 and influenza
vaccines may have reduced the actual incidence.
AOM is defined as the rapid onset of signs and symptoms of inflammation in
the middle ear. It is considered severe if there is moderate to severe otalgia or
fever >39°C (102.2°F). Aside from ear pain, reported in only 50% to 60% of
children with AOM, symptoms of AOM such as irritability, ear tugging, sleep
disruption, and fever are variable and nonspecific. Using strict but appropriate
otoscopic criteria, a majority of children whose parent suspects AOM in fact have
uncomplicated upper respiratory infection (URI).
Examination of the TM is one of the most difficult clinical skills to master.
Agreement on AOM diagnosis between otolaryngologists, the gold standard, and
pediatricians or family physicians is abysmal. Improved training in the diagnosis
of AOM and careful physical examination is clearly warranted.
In younger children with respiratory symptoms, fever, or specific ear
symptoms, adequate visualization of the TM is required. Despite the increasing
pressure to manage and make a disposition for patients quickly, clinicians must
take the time to accurately determine if AOM is present. Removal of cerumen
with saline irrigation, peroxide-containing ear drops, docusate sodium syrup,
and/or curettage will be a frequent procedure for clinicians caring for children.
Immobilization of the uncooperative child may be required and proper equipment
must be available.
Bulging of the TM is the physical finding most specific for the presence of a
bacterial pathogen in middle ear fluid ( Fig. 58.2 A–D ). In children with acute
symptoms, impaired TM mobility with pneumatic otoscopy and the presence of
cloudy middle ear fluid are also strongly correlated with bacterial infection. A
TM that appears hemorrhagic or strongly red is associated with AOM, but lesser
degrees of redness are not useful diagnostically. Occasionally, examination of a
child with AOM will reveal bullae on the TM. The organisms responsible for
“bullous myringitis” are not significantly different from other cases of AOM and
treatment should be similar. Children with AOM and TM perforation may present
with purulent otorrhea that prevents adequate visualization of the TM. Otitis
externa can usually be excluded on clinical grounds, so a presumptive diagnosis
of AOM with perforation can be made.
Otitis media with effusion (OME) is the current term for a condition described
by fluid in the middle ear cavity without signs and symptoms of acute
