Symptoms of Otitis Media
Otitis media presents differently depending on the type: acute otitis media (AOM) features rapid-onset ear pain, fever, and irritability, while otitis media with effusion (OME) typically presents with hearing loss without acute infectious symptoms. 1
Acute Otitis Media (AOM) Symptoms
Ear-Specific Symptoms
- Otalgia (ear pain) is the most useful symptom for diagnosing AOM 2
- Ear pulling or tugging in infants serves as a behavioral indicator of ear pain 2, 1
- Otorrhea (ear discharge) indicates middle ear effusion with possible tympanic membrane perforation 2, 1
Systemic and Non-Specific Symptoms
- Fever occurs commonly but is not always present 2, 1
- Irritability in infants and toddlers is a frequent presenting complaint 2, 1
- Sleep disturbance may accompany acute episodes 2
- Anorexia can occur during acute illness 2
- Nausea and vomiting are less common but recognized symptoms 2
Critical Diagnostic Caveat
Clinical history alone is poorly predictive of AOM, especially in younger children 2, 1, making physical examination with pneumatic otoscopy essential for accurate diagnosis.
Otitis Media with Effusion (OME) Symptoms
Primary Presentation
- Hearing loss (conductive) is the most useful symptom for diagnosing OME 2, 1
- Absence of acute infectious symptoms (no fever, no acute ear pain) distinguishes OME from AOM 1
- Middle ear effusion behind an intact tympanic membrane without signs of acute inflammation 1
Secondary Complications
- Language delays can develop when hearing loss persists 1
- Behavioral issues and academic difficulties may be associated with chronic OME 1
- Balance problems occasionally occur 1
Physical Examination Findings
AOM Findings
- Bulging tympanic membrane is the most useful physical finding for diagnosing AOM 2
- Distinct erythema of the tympanic membrane indicates middle ear inflammation 2, 1
- Limited or absent tympanic membrane mobility on pneumatic otoscopy indicates middle ear effusion 2, 1
- Air-fluid level behind the tympanic membrane confirms effusion 2
OME Findings
- Opaque or cloudy tympanic membrane is most useful for diagnosing OME 2
- Minimal or sluggish tympanic membrane movement with applied pressure indicates fluid presence 2
Diagnostic Requirements for AOM
The diagnosis of AOM requires three essential elements 2, 1:
- Acute onset of signs and symptoms (recent, usually abrupt onset) 2
- Presence of middle ear effusion (documented by bulging, limited mobility, air-fluid level, or otorrhea) 2
- Signs of middle ear inflammation (distinct erythema or fullness/bulging with color changes) 2
Treatment Considerations
Pain Management
Pain assessment and management should be addressed in all AOM cases, especially during the first 24 hours, regardless of antibiotic use 2. This is a strong recommendation based on the preponderance of benefit over risk 2.
Antibiotic Therapy
- High-dose amoxicillin (80 to 90 mg per kg per day) is the first-line antibiotic for most children with AOM 2, 3
- Observation without antibiotics is appropriate for selected children 6 months to 2 years with non-severe illness and uncertain diagnosis, or children ≥2 years without severe symptoms 2
- Azithromycin or cefdinir should be first-line in penicillin-allergic patients 3
Important Pitfall
Distinguishing AOM from OME is difficult and commonly leads to unnecessary antibiotic prescriptions when OME is mistaken for AOM 2. Factors increasing diagnostic uncertainty include cerumen obstruction, narrow ear canals, and inability to achieve adequate seal for pneumatic otoscopy 2.