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Summary Table

Category	Detail
Risk Factors	Age 6 to 24 months, daycare attendance, bottle-feeding in supine position, exposure to tobacco smoke, cleft palate, Down syndrome, recent URI, non-breastfed infants
Etiology	Streptococcus pneumoniae (most common), non-typeable Haemophilus influenzae, Moraxella catarrhalis
Patient Presentation	Ear pain (otalgia), fever, irritability, ear tugging in infants, often preceded by upper respiratory symptoms
Classic Physical Exam	Bulging, erythematous, opacified tympanic membrane with decreased mobility on pneumatic otoscopy; may see purulent otorrhea if TM has perforated
Key Diagnostic Results	Clinical diagnosis based on otoscopic findings; tympanometry shows flat (type B) curve; no labs or imaging required in uncomplicated cases
Management	High-dose amoxicillin (80 to 90 mg/kg/day) is first-line; observation option for mild cases in children older than 2 years with unilateral disease
Keywords	"Bulging TM," "decreased TM mobility," "air-fluid levels behind the TM," "recent URI followed by ear pain and fever," "crying and pulling at ear"

1. Pathophysiology

Acute otitis media develops when the Eustachian tube becomes dysfunctional, most commonly following a viral upper respiratory infection. In children, the Eustachian tube is shorter, more horizontal, and more compliant than in adults, which makes it far more susceptible to obstruction and reflux of nasopharyngeal secretions into the middle ear space.

When the Eustachian tube becomes edematous and obstructed, negative pressure develops in the middle ear. This creates a vacuum effect that draws nasopharyngeal bacteria into the middle ear cavity. Bacterial colonization within a closed, poorly ventilated space then triggers an acute inflammatory response: neutrophilic infiltration, mucosal edema, and purulent fluid accumulation. This collection of fluid under pressure is what produces the bulging tympanic membrane seen on exam and explains the intense otalgia.

The reason young children present with irritability and ear tugging rather than verbalizing pain is developmental. An infant cannot localize or describe otalgia, so behavioral cues become the surrogate complaint. Fever results from the systemic inflammatory response to bacterial infection. Spontaneous perforation of the TM may occur when pressure exceeds the membrane's structural tolerance, and this paradoxically relieves pain while producing purulent otorrhea.

The predilection for S. pneumoniae and non-typeable H. influenzae reflects the normal nasopharyngeal flora of children. M. catarrhalis is the third most common organism and is notable for near-universal beta-lactamase production, which becomes relevant when choosing antibiotics after treatment failure.

2. Classification and Clinical Manifestation

Classification	Definition	Clinical Features
AOM (Nonsevere)	Mild otalgia for less than 48 hours, temperature below 39 C	Moderate bulging of TM, mild erythema, child is not toxic-appearing
AOM (Severe)	Moderate to severe otalgia OR temperature 39 C or higher OR otalgia lasting 48 hours or more	Marked bulging, intense erythema, possible TM perforation with otorrhea, child appears ill
AOM with Otorrhea	Purulent drainage through a perforated TM or tympanostomy tube	Sudden relief of pain followed by ear discharge; TM perforation visible on otoscopy
Recurrent AOM	Three or more episodes in 6 months OR four or more in 12 months with at least one in the past 6 months	Repeated presentations with symptom-free intervals between episodes
AOM with Complications	Extension of infection beyond the middle ear	Mastoiditis (postauricular swelling, protrusion of auricle), intracranial abscess, facial nerve palsy, labyrinthitis

A key clinical distinction tested on exams is the difference between AOM and otitis media with effusion (OME). In OME, there is fluid behind the TM but no signs of acute infection (no bulging, no erythema, no fever, no otalgia). OME typically follows a resolved episode of AOM or results from chronic Eustachian tube dysfunction. The TM in OME appears retracted or neutral with an air-fluid level or amber discoloration, and mobility is decreased but there is no bulging. This distinction matters because OME does not require antibiotics.

3. Diagnostic Workup

Test	Role	Expected Finding
Pneumatic otoscopy	Best initial test and primary diagnostic tool	Bulging, erythematous, opacified TM with decreased or absent mobility
Tympanometry	Adjunct when otoscopy is equivocal	Type B (flat) curve indicating fluid in the middle ear
Tympanocentesis	Gold standard / most accurate test	Aspiration of middle ear fluid for culture and sensitivity; confirms organism and guides therapy
CT temporal bone	Only if complication suspected (mastoiditis, intracranial extension)	Opacification of mastoid air cells, bony erosion, abscess formation

Pneumatic otoscopy is the cornerstone of diagnosis. The examiner attaches a rubber bulb to the otoscope and applies positive and negative pressure to assess TM mobility. A normal TM moves briskly in response to pressure changes. In AOM, the TM is immobile or has markedly reduced mobility because of fluid and pressure behind it. The combination of a bulging TM plus decreased mobility is the most reliable otoscopic finding for diagnosing AOM. Erythema alone is not sufficient, as crying can cause TM redness.

Tympanometry is used when direct visualization is difficult (cerumen obstruction, uncooperative child) or when otoscopic findings are ambiguous. A type B curve (flat tracing with no peak) indicates fluid in the middle ear space. A type C curve (peak shifted to the left/negative pressure) suggests Eustachian tube dysfunction without fluid and is more consistent with OME.

Tympanocentesis is not performed routinely. It is reserved for treatment failure after second-line antibiotics, neonates under 8 weeks with AOM (due to risk of unusual organisms like gram-negative enterics), immunocompromised patients, and suspected suppurative complications. It provides definitive microbiologic diagnosis.

No blood work, no cultures from the ear canal surface, and no imaging are needed for uncomplicated AOM. Exam vignettes that offer CT scan or MRI as answer choices for a straightforward case of AOM are distractors.

4. Management and Treatment

Scenario	Treatment	Details
Severe AOM (any age)	High-dose amoxicillin	80 to 90 mg/kg/day divided BID for 10 days (children under 2 years) or 7 days (2 to 5 years) or 5 to 7 days (6 years and older)
Nonsevere AOM, age 6 to 23 months, unilateral	Observation OR amoxicillin	Observation with close follow-up in 48 to 72 hours is acceptable; treat if worsening or no improvement
Nonsevere AOM, age 24 months and older, unilateral	Observation preferred	Safety-net antibiotic prescription (filled only if symptoms persist or worsen in 48 to 72 hours)
Nonsevere AOM, bilateral, age 6 to 23 months	High-dose amoxicillin	Bilateral disease in young children warrants treatment regardless of severity
Treatment failure after 48 to 72 hours of amoxicillin	High-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component)	Targets beta-lactamase producing H. influenzae and M. catarrhalis
Second treatment failure	Tympanocentesis for culture OR clindamycin (if pneumococcal resistance suspected) OR ceftriaxone IM (50 mg/kg x 3 days)	Tympanocentesis becomes both diagnostic and therapeutic
Penicillin allergy (non-anaphylactic)	Cefdinir, cefuroxime, or cefpodoxime	Second or third-generation cephalosporins with adequate middle ear penetration
Penicillin allergy (anaphylactic/severe)	Azithromycin or clarithromycin	Less effective against resistant pneumococci; use only when beta-lactams are truly contraindicated
Recurrent AOM	Tympanostomy tube placement	Referral to ENT; tubes ventilate the middle ear and prevent fluid accumulation

The first decision point is whether to treat or observe. The observation option exists because many AOM episodes (particularly those caused by H. influenzae and M. catarrhalis) resolve spontaneously. However, observation is only appropriate when reliable follow-up is ensured and caregivers understand the safety-net plan.

When antibiotics are indicated, high-dose amoxicillin at 80 to 90 mg/kg/day divided into two doses is the universal first-line agent. The high dose is necessary to overcome intermediate penicillin resistance in S. pneumoniae, which is the most common and most dangerous pathogen. Standard-dose amoxicillin (40 mg/kg/day) is no longer recommended due to increasing pneumococcal resistance.

If the child fails to improve after 48 to 72 hours, the next step is amoxicillin-clavulanate, not a fluoroquinolone or macrolide. The addition of clavulanate addresses beta-lactamase producers (H. influenzae, M. catarrhalis) while maintaining the high amoxicillin dose for pneumococcal coverage.

Ceftriaxone IM (single dose of 50 mg/kg) is an alternative first-line agent for children who are vomiting and cannot tolerate oral medication. A three-day IM course is used for treatment failures.

Pain management is essential and often undertested. Analgesics (acetaminophen or ibuprofen) should be given to all patients regardless of whether antibiotics are prescribed. Topical anesthetic drops (benzocaine-antipyrine) can be used if the TM is intact.

Decongestants and antihistamines have no role in treating AOM and should not be selected on exam questions.

For recurrent AOM, prophylactic antibiotics are no longer recommended. The current standard is referral for tympanostomy tube placement, which provides continuous ventilation of the middle ear space.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Otitis media with effusion (OME)	Fluid behind TM, decreased mobility, conductive hearing loss	No signs of acute infection: no bulging, no erythema, no fever, no otalgia; TM appears retracted or neutral with air-fluid level
Otitis externa (swimmer's ear)	Ear pain, possible discharge	Tragal tenderness and pain with manipulation of the pinna; TM is normal; ear canal is erythematous and edematous
Referred otalgia (dental/TMJ)	Ear pain as chief complaint	Normal otoscopic exam; pain reproduced by jaw movement or dental percussion
Cholesteatoma	Otorrhea, hearing loss, can follow chronic otitis media	Pearly white mass or retraction pocket in the posterosuperior TM; foul-smelling discharge; conductive hearing loss out of proportion to exam findings
Mastoiditis	Follows AOM, fever, ear pain	Postauricular erythema, swelling, and tenderness with outward displacement of the auricle; requires CT imaging and IV antibiotics
Foreign body in ear canal	Unilateral otalgia, discharge	Visualized on otoscopy; TM is normal if object has not perforated it; history often involves a young child

6. Traps and High-Yield Pearls

The most common way students lose points on AOM questions is by confusing AOM with OME. Both involve middle ear fluid and decreased TM mobility, but only AOM has acute inflammatory signs (bulging, erythema, otalgia, fever). When a vignette describes a child with hearing difficulty and a retracted TM with an air-fluid level but no pain and no fever, the answer is OME and the management is watchful waiting, not antibiotics.

A second frequent trap is selecting standard-dose amoxicillin instead of high-dose amoxicillin. Test writers will often include both as answer choices, and students who remember "amoxicillin is first-line" but forget the dose pick the wrong option.

Another tested concept is the observation option. Vignettes will present a well-appearing child older than 2 years with mild unilateral AOM and ask for the next best step. Students who reflexively choose antibiotics for every AOM case will miss this. The correct answer is observation with a safety-net prescription, provided follow-up is reliable.

Finally, be alert for the AOM-to-mastoiditis progression vignette. If a child with recently treated AOM returns with postauricular swelling, protrusion of the ear, and persistent high fever, this is acute mastoiditis until proven otherwise. The next step is CT of the temporal bone and IV antibiotics, not a repeat course of oral amoxicillin. This tests your ability to recognize when a common condition has developed an uncommon complication.

The core competency being tested across AOM questions is your ability to stratify severity, match the right treatment intensity to the clinical scenario, and distinguish AOM from its look-alikes based on otoscopic findings.

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