What are the signs and symptoms of otitis media?

Signs and Symptoms of Otitis Media

Acute otitis media presents with rapid onset of ear pain, irritability, and fever, while the key diagnostic finding is a bulging tympanic membrane with impaired mobility. 1, 2

Clinical Presentation by Type

Acute Otitis Media (AOM)

Symptom Triad:

• Rapid, abrupt onset of signs and symptoms is the hallmark feature that distinguishes AOM from other middle ear conditions 1, 2
• Otalgia (ear pain) is the most consistent symptom, occurring in 50-60% of children; in infants and preverbal children, this manifests as ear pulling, tugging, rubbing, or holding the ear 1, 2, 3
• Fever is present in many cases but is not required for diagnosis and is less reliable than ear pain 2, 4

Additional Symptoms:

• Irritability in infants and toddlers is a common presenting feature 1, 2, 3
• Otorrhea (ear drainage) indicates tympanic membrane perforation 1, 2, 3
• Sleep disturbances and changes in behavior patterns are frequently observed 3
• Excessive crying in young preverbal children 3
• Anorexia, vomiting, or lethargy may occur in some cases 5

Critical Physical Examination Findings:

• Bulging of the tympanic membrane is the most predictive finding with 97% specificity for bacterial AOM and is the most consistent sign differentiating AOM from OME 1, 2, 3
• Limited or absent mobility of the tympanic membrane on pneumatic otoscopy has the highest sensitivity and specificity (approximately 95% and 85%, respectively) 1, 3
• Distinct erythema of the tympanic membrane indicates middle ear inflammation 1, 2, 3
• Air-fluid level behind the tympanic membrane 1, 2, 3
• Cloudy or opaque tympanic membrane has high sensitivity (74%) and specificity (93%) for AOM 1, 3

Otitis Media with Effusion (OME)

Key Distinguishing Features:

• Hearing loss (conductive in nature) is the primary presenting symptom, unlike AOM 2
• Absence of acute infectious symptoms such as fever and acute ear pain distinguishes OME from AOM 2
• Middle ear effusion present behind an intact tympanic membrane without signs of acute inflammation 2
• Language delays can develop when hearing loss persists 2
• Behavioral issues and academic difficulties may be associated with chronic OME 2

Critical Diagnostic Considerations

The AAP/AAFP diagnostic criteria require ALL three elements: 1, 2, 3

1. Acute onset of signs and symptoms
2. Presence of middle ear effusion
3. Signs and symptoms of middle ear inflammation

Important Clinical Pitfalls:

• Clinical history alone is poorly predictive of AOM, especially in younger children, making physical examination with pneumatic otoscopy essential 1, 2, 3
• Distinguishing AOM from OME is difficult and commonly leads to unnecessary antibiotic prescriptions when OME is mistaken for AOM 1, 2
• Cerumen obstruction preventing adequate visualization must be removed to facilitate accurate diagnosis 1

Age-Related Patterns

• Peak incidence occurs in the first year of life with 45.3 new episodes per 100 children per year 2
• Highest rates occur in children 1-4 years of age with 61 new episodes per 100 children per year 2
• By age 3, 50-85% of children will have had at least one AOM episode 2, 5

Red Flag Symptoms Requiring Urgent Evaluation

Immediate emergency warning signs include: 6

• Altered mental status, confusion, or decreased responsiveness (may indicate meningitis or intracranial abscess)
• Severe headache with vomiting
• Stiff neck (nuchal rigidity)
• Bulging fontanelle in infants
• Seizures or focal neurological deficits
• Swelling, redness, or tenderness behind the ear (suggests acute mastoiditis)