What are the typical presentations of otitis media?

Typical Presentations of Otitis Media

Otitis media presents differently depending on its subtype: acute otitis media (AOM) manifests with rapid-onset ear pain, fever, and a bulging tympanic membrane, while otitis media with effusion (OME) typically presents with hearing loss without acute infectious symptoms. 1

Acute Otitis Media (AOM) Presentation

Cardinal Features

• Rapid onset of signs and symptoms (usually abrupt) 1
• Otalgia (ear pain) or ear pulling/tugging in infants 1, 2
• Fever (though not always present) 1, 3, 2
• Irritability in infants and toddlers 1, 2
• Otorrhea (ear discharge) 1, 2

Additional Symptoms

• Anorexia 2
• Vomiting or lethargy (occasionally) 2
• General illness and distress 1

Physical Examination Findings

The diagnosis requires three essential elements: acute onset, middle ear effusion, and signs of middle ear inflammation 1

Middle ear effusion indicators:

• Bulging of the tympanic membrane (most predictive finding) 1, 2
• Limited or absent mobility of the tympanic membrane 1
• Air-fluid level behind the tympanic membrane 1
• Otorrhea 1

Signs of inflammation:

• Distinct erythema of the tympanic membrane 1
• Fullness or bulging combined with color changes and decreased mobility 1

Otitis Media with Effusion (OME) Presentation

Key Distinguishing Features

• Hearing loss is the primary symptom (conductive in nature) 1, 4
• Absence of acute infectious symptoms (no fever, no acute ear pain) 1, 3
• Middle ear effusion present behind an intact tympanic membrane 1
• Often asymptomatic or minimally symptomatic 5

Associated Problems

• Language delays (when hearing loss persists) 1
• Behavioral issues 1
• Academic difficulties 1
• Balance problems (occasionally) 4

Chronic Suppurative Otitis Media (CSOM) Presentation

• Persistent drainage from the middle ear through a perforated tympanic membrane 4
• Leading cause of hearing loss in developing countries 1

Important Clinical Pitfalls

Diagnostic Challenges

Clinical history alone is poorly predictive of AOM, especially in younger children 1. This is a critical pitfall—relying on symptoms without proper otoscopic examination leads to misdiagnosis.

Distinguishing AOM from OME is difficult and commonly leads to unnecessary antibiotic prescriptions when OME is mistaken for AOM 1. The key differentiator is the presence or absence of acute infectious symptoms.

Examination Obstacles

Common factors that increase diagnostic uncertainty include 1:

• Cerumen obscuring the external auditory canal
• Narrow ear canals
• Inability to maintain adequate seal for pneumatic otoscopy or tympanometry

Age-Related Patterns

• Peak incidence occurs in the first year of life (45.3 new episodes per 100 children per year) 1
• Highest rates in children 1-4 years of age (61 new episodes per 100 children per year) 1
• By age 3, 50-85% of children will have had at least one AOM episode 2
• 80% of children will have had at least one OME episode by age 10 1

Associated Context

AOM typically occurs as a complication of viral upper respiratory tract infection with eustachian tube dysfunction 3, 5. Common viruses include respiratory syncytial virus, rhinovirus, adenovirus, parainfluenza, and coronavirus 5.