ARTICLE

Acute Otitis Media

Caroline R. Paul, MD,1 John G. Frohna, MD, MPH2
1
Department of Pediatrics, NYU Grossman School of Medicine, NYU Langone Health, New York
2
Department of Pediatrics, West Virginia School of Medicine-Charleston Division, Charleston Area
Medical Center Institute for Academic Medicine, Charleston, West Virginia

EDUCATION GAP
There remains a gap in the implementation of the appropriate diagnostic
criteria and management of acute otitis media.

OBJECTIVES After completing this article, readers should be able to:

1. List the diagnostic criteria for acute otitis media.

2. Discuss the therapeutic management of acute otitis media.
3. Describe the components of the pediatric otoscopic exam needed for the
management of acute otitis media.
4. Describe the important role of the parent/caregiver in the diagnosis and
the management of acute otitis media.

Acute otitis media (AOM) is the most common cause for antimicrobial treatment in
young children, accounting for 56% of antimicrobial prescriptions for children aged
3 to 36 months and 40% of antimicrobial prescriptions for children aged 3 to
6 years.1,2 It is the second most common diagnosis after upper respiratory infection
in children. The epidemiology of AOM has international and regional variances and
has been impacted by both pneumococcal vaccines and the COVID-19 pandemic.3,4
Approximately 50% of children will have 1 episode of AOM by age 2 years, and by age
3 years, 80% will have had at least 1 episode.5
Health disparities have been noted in children with AOM.6 Children who are
socially disadvantaged are less likely to receive treatment and more likely to experience
complications of misdiagnosed and mismanaged episodes of AOM. Frequent ear
infections have been associated with living below the poverty level. In under-resourced
countries, chronic supportive otitis media is a leading cause of hearing loss.7 AUTHOR DISCLOSURE: Drs Paul and
Frohna have disclosed no financial
relationships relevant to this article. This
commentary does not contain a
CLINICAL PRESENTATION
discussion of an unapproved/
The most specific symptom of AOM is acute otalgia. This acute otalgia can manifest investigative use of a commercial
product/device.
in many ways, from the acute onset of ear pain in the school-aged child to nighttime
awakening, fussiness, and decreased appetite in younger children. While the acute
ABBREVIATIONS
otalgia is usually constant, it often appears to be worse in the evening. Fever can be
AAP American Academy of Pediatrics
associated with AOM but is not a consistent finding associated with AOM. Finally,
AOM acute otitis media
recent or concurrent upper respiratory infection symptoms such as nasal congestion OME otitis media with effusion
will often accompany the key symptoms of AOM.8 TM tympanic membrane

Vol. 46 No. 3 M A R C H 2 0 2 5 139

Downloaded from http://publications.aap.org/pediatricsinreview/article-pdf/46/3/139/1774529/pedsinreview.2023006216.pdf

by New York City Health & Hospitals, Juan Sosa
 EPIDEMIOLOGY DIAGNOSIS
The peak incidence of AOM is between age 6 to 12 months. It The diagnosis of AOM rests on the visualization of the tym-
is multifactorial in terms of risk factors, with males being at a panic membrane and clinician competence in performing
slightly higher risk than females. Genetic predisposition, pas- the overall ear exam.13 Therefore, it is important to under-
sive smoke exposure, conditions associated with decreased stand the diagnostic criteria and to be proficient in perform-
immunity, ciliary dysfunction, cochlear implants, daycare ing the pediatric ear exam. The accurate diagnosis of AOM
attendance, and family history of recurrent AOM in parents facilitates the appropriate usage of antimicrobial therapy
or siblings are other risk factors associated with AOM.2 for AOM. This also helps to mitigate the unnecessary use
AOM can be caused by viruses, bacteria, or a combination of antibiotics, thereby decreasing the overuse of antibiotics
of both. Bacterial causes include the most common bacteria in general. Rising health care costs, increasing antibiotic
that occupy the upper respiratory tract: Streptococcus pneumo- resistance, and the possible need for surgical referrals for
niae, non-typeable Haemophilus influenzae, and Moraxella recurrent AOM stress the critical importance of an accurate
catarrhalis. Since the implementation of conjugate pneumo- diagnosis of AOM.
coccal vaccines, AOM is more commonly caused by nonvac- Understanding the anatomy of the middle ear is essen-
cine serotypes. In terms of viral causes of AOM, the most tial to making an accurate diagnosis of AOM. The middle
common viral pathogens of otitis media include respiratory ear is the area between the tympanic membrane (which sep-
syncytial virus, adenovirus, influenza viruses, coronaviruses, arates the external and middle ear spaces) and the oval/
human metapneumovirus, and picornaviruses. Infection round windows (which mark the beginning of the inner
with both viruses and bacteria is quite common, with one ear). The eustachian tube connects the upper respiratory
study documenting 66% coinfection rates.9 tract to the middle ear and is more horizontal in infants
Many practicing clinicians likely noticed a significant and children. Several resources are available that physicians
decrease in the incidence of AOM during the COVID-19 pan- can use to explain to parents how AOM may arise in their
demic. Several studies documented this decrease, along with child.14
a decrease in the use of antibiotics and emergency depart- When examining a normal tympanic membrane (TM),
ment visits for AOM.10,11 This decrease has largely been the membrane appears translucent, and the malleus is often
attributed to the social distancing and mask use that was seen through the TM in the anterior-superior quadrant
in place during the pandemic. The incidence of other viral (Figure 1). On the other hand, in cases of AOM, the diagnosis
respiratory infections was also decreased during this time. is dependent on a bulging TM (Figures 2 and 3). There is
The presence of SARS-CoV2 in patients with AOM has also often decreased mobility of the TM, and the color is often ery-
been documented, suggesting that the 2 conditions can thematous with purulent and turbid fluid behind the mem-
coexist.12 brane, suggestive of a bacterial infection.

PATHOPHYSIOLOGY
AOM results from the acute inflammation of fluid in the
middle ear space, which is dense with bacterial otopatho-
gens. Many factors contribute to the acute inflammatory
cycle, including bacterial persistence, viral infections, aller-
gic rhinitis, recent or current upper respiratory infection,
and anatomic variation and abnormalities, which set up
the genesis of AOM.7 The eustachian tube is particularly
essential in protecting the middle ear space from bacterial
pathogens and viruses. A properly functioning eustachian
tube is essential to the drainage of secretions. The eusta-
chian tube also serves to equalize pressures. In young chil-
dren under 2 years of age, the eustachian tube is less
effective in these functions because it sits in a more hori-
zontal position, leading to a slower drainage of secretions
and allowing for more transmission of pathogens into the FIGURE 1. Visualization of the normal tympanic membrane. Image
middle ear space. courtesy of ePROM.17,20

140 Pediatrics in Review

Downloaded from http://publications.aap.org/pediatricsinreview/article-pdf/46/3/139/1774529/pedsinreview.2023006216.pdf

by New York City Health & Hospitals, Juan Sosa
 FIGURE 2. Visualization of the tympanic membrane in a patient with FIGURE 4. Visualization of the tympanic membrane in a patient with
acute otitis media. Image courtesy of ePROM.17,20 otitis media with effusion. Image courtesy of ePROM.17,20

with regards to age, development status, and the severity of

their illness. This will guide the examiner’s approach to the
ear exam. Using an appropriate otoscope that provides
adequate illumination and resolution to visualize the TM will
allow the examiner to make a diagnosis of AOM. It is also
important to use an otoscope that allows for the pneumatic
otoscopy. Appropriately sized scope tips should be used
based on the size of the child and the presence of any cranio-
facial anomalies. In addition, other developmental needs of
the child should be considered; for instance, some children
may be afraid of the light from the otoscope, thinking that it
may be hot or too bright for their eyes.
Next, the examiner should attend to the positioning of the
patient. The school-aged child is likely to be on the examining
table, and an otoscopy exam can generally be done with
FIGURE 3. Visualization of the tympanic membrane in a patient with appropriate distraction and gentleness without the aid of
acute otitis media. Image courtesy of ePROM.17,20 a parent or caregiver. The younger child should be on the
lap of the parent/caregiver or on the examining table with
Physical Examination parent/caregiver assistance. Generally, infants younger than
Training in pediatric otoscopy involves learning how 9 months should be on the examining table in a supine posi-
to perform a proper ear exam in a child, which includes tion for a safe exam. An effective otoscopy exam does not nec-
the use of appropriate techniques for holding and distract- essarily require a lot of time. A “few golden minutes” should
ing a child, performing pneumatic otoscopy, and removing suffice in the absence of cerumen; during this time, the child
cerumen. A checklist (Table 1) containing the essential com- is held in a comforting position that allows the examiner to
ponents of a pediatric ear exam has been shown to be help- perform a double-handed exam in which the nondominant
ful in teaching settings.15,16 It is important to remain hand is used to steady the head, and the dominant hand
proficient in pneumatic otoscopy and cerumen removal manipulates the otoscope to visualize the TM.
because it has been shown that these skills can decline Once the examiner can see the anatomy, the examiner
over time.17 should take note of various characteristics of the TM,
The examiner should perform a deliberate, stepwise including the position of the TM, the color, presence of
exam. When performing the otoscopy exam, it is important the bony landmarks, translucency of the TM, and any
to first determine the overall status of the patient, especially discharge.18

Vol. 46 No. 3 M A R C H 2 0 2 5 141

Downloaded from http://publications.aap.org/pediatricsinreview/article-pdf/46/3/139/1774529/pedsinreview.2023006216.pdf

by New York City Health & Hospitals, Juan Sosa
 TABLE 1. Standardized Checklist for Otoscopy Performance Evaluation (SCOPE)15

GENERAL EXAMINATIONa
Discussion with caregiver
1. □Yes □No Discussed the need for otoscopic assessment
2. □Yes □No No Described the possible need to remove cerumen to view ear
3. □Yes □No Described positioning and the possible need for secure holding method
Equipment
4. □Yes □No Selected appropriate size ear speculum for proper seal and comfort to patient, given child’s age/size Age___ Size___
Positioning
5. □Yes □No Ensured appropriate position (including caregiver assisted) for patient based on age and/or developmental status of patient
6. □Yes □No □NA If needed, assured that child’s head was appropriately secured
7. □Yes □No □NA If not able to perform step 6, asked for assistance from caregiver
Distraction techniques
8. □Yes □No Used distraction techniques appropriate for age/development stage
Otoscopic examination
9. □Yes □No Inserted otoscope with dominant hand
10. □Yes □No Stabilized otoscope either by one-handed or two-handed method
11. □Yes □No Manipulated auricle to facilitate view of TM
12. □Yes □No Stabilized otoscope by bracing finger/dorsum of hand on infant/child’s face or head
CERUMEN REMOVAL
13. □Yes □No Identified need for cerumen removal
14. □Yes □No Asked appropriately for assistance
15. □Yes □No Secured and/or distracted child prior to removal attempt
16. □Yes □No Stabilized head
17. □Yes □No Used scope appropriately to aid in removal of cerumen
18. □Yes □No Used appropriate instrument for removal
19. □Yes □No Able to remove some cerumen but inadequate for appropriate TM visualization
______removed via direct visualization via open-headed otoscope
______removed via indirect visualization
20. □Yes □No Appropriately identified that cerumen removal was inadequate for TM visualization
21. □Yes □No Able to remove adequate cerumen for appropriate visualization of TM
______removed via direct visualization
______removed via indirect visualization
PNEUMATIC OTOSCOPY
22. □Yes □No Appropriately attaches insufflators to otoscope
23. □Yes □No Uses appropriate speculum size: Age_____ Size____
24. □Yes □No Checks for airtight seal
25. □Yes □No Use insufflator with patient appropriately
DIAGNOSIS
Abbreviations: NA, not applicable; TM, tympanic membrane
a
Reprinted with permission

TABLE 2. Guidance for Parent and Caregiver Communication

Talking Points to Consider
1. Pain control: The common symptom of an acute middle ear infection is acute pain. Please discuss with your health care provider about
pain management for your child.
2. Access to care: Ensure you have access to a health care provider in 24 to 72 hours after the diagnosis of an acute middle ear infection
has been made.
3. Risk factors: Consider risk factors you can remove in your child’s environment such as smoking.
4. Recognize that your provider cannot diagnose an ear infection without performing an ear exam on your child.
5. Know that antibiotics are not always needed; talk to your health care provider.
6. Seek care if your child is not getting better in 48 to 72 hours and sooner with acute and worsening symptoms.

142 Pediatrics in Review

Downloaded from http://publications.aap.org/pediatricsinreview/article-pdf/46/3/139/1774529/pedsinreview.2023006216.pdf

by New York City Health & Hospitals, Juan Sosa
 Pneumatic otoscopy is an integral component of the over- other associated findings of acute inflammation of the
all pediatric ear exam. It allows for the visualization of the middle ear effusions such as a purulent color of the TM.
movement of the TM based on pressure changes. It is helpful The management of OME is supportive and requires no
in determining the presence of effusion in the middle ear medications. Still, OME must be followed up until resolu-
space. Performing pneumonic otoscopy requires the exam- tion. It is important to document resolution of any abnor-
iner to be adept at the basic otoscopy skills described above. mal TM finding so as to not overlook chronic OME or
It involves attaching a bulb to the otoscope and then applying other conditions that might present initially in a similar
positive pressure (deflation of the bulb) and negative pres- manner such as a cholesteatoma. Of note, despite the dis-
sure (inflation of the bulb). tortion of the TM, OME does not represent an acute virulent
Many TM conditions can be associated with abnormal bacterial infection of the middle ear fluid. Therefore, OME
responses to positive and negative pressures. Most often, does not necessitate the use of antibiotics.
the reason for impaired mobility of the TM is due to effusion Chronic OME is defined as the persistence of middle ear
in the middle ear space. As AOM involves the accumulation effusion for more than 3 months. Evaluation by an otolaryn-
of fluid in the middle space, impaired movement of the gologist is recommended for children with unresolved OME
TM as determined by pneumatic otoscopy is associated and atypical symptoms accompanying OME such as concern
with AOM. Still, pneumatic otoscopy does not differentiate for worsening hearing. Thus, is it important to be able to dif-
between serous and purulent effusion. Importantly, it can ferentiate between the tympanic findings of OME and AOM,
also be the first step in the evaluation for other more concern- stressing again the importance of competency in the exami-
ing etiologies such as cholesteatoma. A child with impaired nation of the middle ear.13,19
mobility of the TM as determined by pneumatic otoscopy
should be followed closely.
The 2013 American Academy of Pediatrics (AAP) guide- MANAGEMENT AND TREATMENT
line provides a framework for the diagnosis of AOM.8 It is The management and therapies discussed here will be broad
important to recognize that the bulging of the TM is required based and follow evidence-based criteria. Pediatricians
in each of these criteria in order to make the diagnosis of should consider the AAP guideline, studies published follow-
AOM. Below are excerpts from the AAP guideline regarding ing the AAP guideline and the prevalence of pathogens in
the diagnosis of AOM. their community, and should adhere to a strict evidence-
based approach in the treatment of their patient.8 It is vital
• “Statement 1A: Clinicians should diagnose acute otitis that pediatricians continuously update their knowledge
media (AOM) in children who present with moderate to and skills regarding diagnostic criteria, epidemiology, and
severe bulging of the TM or new onset of otorrhea not management plans. Online resources such a peer-reviewed
due to acute otitis externa. Evidence Quality: Grade B. pediatric website offer the pediatrician access to rapid
Strength: Recommendation.” PubMed searches regarding current evidence-based thera-
• “Statement 1B: Clinicians should diagnose AOM in chil- peutic regimens.18,20 It is important to reference only
dren who present with mild bulging of the TM and recent peer-reviewed online resources.
(less than 48 hours) onset of ear pain (holding, tugging,
rubbing of the ear in a nonverbal child) or intense Management Without Antimicrobial Therapy
erythema of the TM. Evidence Quality: Grade C. Strength: Some patients with AOM can be safely managed without
Recommendation.” antimicrobial therapy. The natural history of the condition
is such that the pain and discomfort will resolve after the first
Differential Diagnosis of AOM few days, and the use of antibiotics may result in 1 less day of
Conditions such as otitis media with effusion (OME) symptoms. Safety-net antibiotic prescriptions and other sim-
(Figure 4), pharyngitis, and viral upper respiratory infection ilar protocols21,22 have been described, including in the AAP
can mimic some of the symptoms of AOM. However, the guideline, as a nonantimicrobial management protocol.
acute onset of moderate to severe otalgia is not common Criteria for such management usually include older children
with these other conditions. OME is often associated with with non-severe AOM (mild otalgia for less than 48 hours
abnormal findings of the TM such as air-fluid levels or a and temperature of less than 38.5°C), no other bacterial infec-
prominent short process of the malleus, mild otalgia, and tion, and nontoxic status. These children can be followed
often a sensation of ear fullness or popping when swallow- closely without the use of antimicrobial therapy. Close fol-
ing (Figure 3). With OME, there is no bulging of the TM or low-up is needed, and antibiotics should be started if signs

Vol. 46 No. 3 M A R C H 2 0 2 5 143

Downloaded from http://publications.aap.org/pediatricsinreview/article-pdf/46/3/139/1774529/pedsinreview.2023006216.pdf

by New York City Health & Hospitals, Juan Sosa
 and symptoms worsen or do not improve over 48 to 72 hours. It is recommended that antibiotics with beta-lactamase
Current studies following publication of the AAP guideline coverage for AOM should be prescribed if the patient has
do not support safety-net antibiotic prescriptions and other received amoxicillin in the past 30 days, has concurrent puru-
similar non-antibiotic treatment plans in an evidence-based lent conjunctivitis (suggesting H influenzae infection), and
manner for children younger than 2 years. Studies have has a history of recurrent AOM unresponsive to amoxicillin
shown that withholding antibiotics in children younger than of if one suspects H influenzae as the cause of AOM.
3 years can result in unfavorable outcomes.23 Also, it is pos- Attention should be paid to local prevalence microbiology
sible that many of the cases of AOM that resolved without data as well.8,19
antibiotics may have a viral etiology or may not actually have Since the AAP guideline in 2013, well-regarded studies
been AOM and rather were OME. This again calls for the have emerged with recommended management regimens
need to be competent in the diagnosis of AOM and adhere that differ from the guideline. Especially due to the impact
to the diagnostic gold standard. of pneumococcal vaccines, there have been significant
When managing patients with AOM, a key consideration changes in the prevalence of microorganisms for AOM,27 thus
is the control of pain, recognizing that the acute otalgia of affecting the antimicrobial management of AOM in the pedi-
AOM may resolve only after the first 48 hours of antimicro- atric patient. For instance, in 1999, S pneumoniae accounted
bial therapy. Appropriate nonprescription analgesic medica- for 40% to 45% of AOM, with H influenza (25% to 30%),
tion is the foundation of management of AOM in children. Moraxella catarrhalis (15% to 20%), and Strep pyogenes
Oral acetaminophen or ibuprofen can be used to treat the (3% to 5%) following. In 2017, the pattern was S pneumoniae
otalgia. Aspirin should never be given for pain management. (15% to 25%), H influenza (50% to 60%), M catarrhalis (12% to
There is no evidence that pain caused by AOM is improved by 15%), and S pyogenes (3% to 5%). Overall, there has been
alternating acetaminophen and ibuprofen in children,24 and a decrease in penicillin-resistant S pneumonia. Given these
this regimen can lead to medication dosing errors. Otic drops changes since the AAP guideline, Wald recommends a
for pain can be considered only after a patient has been regimen with “regular dose amoxicillin-clavulanate as the pre-
examined and appropriately diagnosed. Otic drops are ferred treatment (45 mg/kg/day in 2 divided doses of 400 mg/
contraindicated in some conditions, including the presence 57 mg) for children with AOM” for 10 days to treat H influen-
or uncertainly of a ruptured TM. zae and penicillin-sensitive S pneumoniae as initial therapy.27
Shared decision-making with families is appropriate in Pediatric clinicians should continue to monitor changes in
almost all cases of AOM. Indeed, educating the parent/care- microbial prevalence and resistance patterns to continue prac-
giver about the diagnosis of AOM and the indications for ticing in an evidence-based manner.
antimicrobial treatment optimizes the overall management Variations in Duration of Amicrobial Therapy. The AAP
of AOM in the pediatric patient. Table 2 shows a script of talk- guideline recommends the traditional 10 days of antimicrobial
ing points that can be used as a guide in the discussion and treatment. Since the publication of the guideline, various stud-
communication of managing AOM with a parent or care- ies have suggested that a 5- or 7-day course may be just as effec-
giver. Additional resources including visual aids appropriate tive as the traditional 10-day course.28 However, Hoberman
for parents are also available to help support parent/caregiver et al demonstrated that a reduced duration of treatment with
education about this condition.14,20,25 amoxicillin-clavulanate involving children aged 6 to 23 months
with AOM was less effective.23 Following the AAP guideline of
Management with Antimicrobial Therapy 10 days of treatment, especially for younger children, seems
The AAP guideline recommends antibiotic therapy for bilat- most prudent currently.
eral AOM in children aged 6 to 23 months even if they do Recommended Antimicrobial Agents. According to the
not have severe signs or symptoms;8 more recently, Wald current AAP guideline, unless the child has an anaphylactic
has urged a similar approach (either treatment or close obser- reaction to penicillin, a course of 80–90 mg/kg/d of amoxi-
vation) to unilateral or bilateral AOM in younger children.26 cillin for 10 days is recommended. In the case of a non–
Clinicians will usually prescribe antibiotic therapy for children type 1 allergic reaction, a cephalosporin such as cefdinir is
with severe signs or symptoms of AOM such as a temperature recommended as first-line therapy.29 Macrolides are not
above 39°C, moderate to severe otalgia, or otalgia for at least indicated in the treatment of AOM due to reported resis-
48 hours. The current AAP guideline recommends amoxicil- tance. Further choices of antimicrobial treatment should be
lin as first line of therapy for children who do not have an based on evidence-based guidance, community prevalence,
allergy to penicillin, have not been on penicillin in the past and resistance patterns, with the advice of a pediatric infec-
30 days, and do not have purulent bilateral conjunctivitis. tious disease specialist as needed.

144 Pediatrics in Review

Downloaded from http://publications.aap.org/pediatricsinreview/article-pdf/46/3/139/1774529/pedsinreview.2023006216.pdf

by New York City Health & Hospitals, Juan Sosa
 If the patient does not respond to amoxicillin in a timely stressing the avoidance of tobacco smoke, pediatricians
manner, an agent such as amoxicillin/clavulanic acid should should encourage the annual influenza vaccination along
be prescribed to treat beta-lactamase–producing agents such with the age-appropriate administration of the pneumococcal
as non-typeable H influenzae. Recent studies of the pharmaco- vaccine as preventive measures for AOM.
kinetics and pharmacodynamics of specific cephalosporins in
respiratory infections suggest against the use of cefdinir in
this scenario.29–31 Rather, intramuscular ceftriaxone should Summary
be considered. Most importantly, the patient who does not • The diagnostic criteria for AOM require the pres-
respond in a timely manner needs to be followed very closely. ence of a bulging TM; there can also be decreased
Access to medical care is important, and the parent/caregiver mobility of the TM, with an erythematous color
needs to be advised carefully as to indications for seeking fur- and/or evidence of purulent, turbid middle ear
ther medical care, including persistent fever, acute changes in fluid. The presence of fever and an erythematous
activity, otorrhea, and mastoid tenderness. TM alone is not diagnostic of AOM.8 (Strength of
Recommendation: Strong)
Management of Patients With Chronic OME
Using antibiotics for prophylaxis to prevent AOM is not indi- • The management of AOM in children includes
cated in pediatric patients.32 Referral to a pediatric otolaryn- pain management and other supportive therapy.
gologist should be considered when AOM is not responding In some circumstances, a wait-and-see approach
to standard antibiotics therapies in a timely manner, in in which the patient is managed without antibiot-
children with complications of AOM such as mastoiditis, ics and the caregivers are provided with a prescrip-
in children with underlying conditions that place them at risk tion for antibiotics and criteria for use may be
for more invasive disease, and for patients with recurrent appropriate.8,21 (Strength of Recommendation:
AOM (defined as 3 episodes in 6 months or 4 episodes in Moderate)
1 year with 1 episode in the preceding 6 months).32,33 • The first-line treatment in patients not allergic to
Special Populations Aged 0 to 8 Weeks penicillin is a 10-day course of 80 to 90 mg/kg/d
Infants younger than 8 weeks diagnosed with AOM should of amoxicillin. Further choices of antimicrobial
be considered higher risk for atypical and severe disease. treatment should be based on evidence-based
Pathogens at this age vary from other age groups; group B guidance, community prevalence, and resistance
strep, gram-negative enteric organisms, and Chlamydia patterns, with the advice of a pediatric infectious
trachomatis should be considered. Febrile neonates with disease specialist as needed.8 (Strength of
AOM should be considered for a full sepsis evaluation. In Recommendation: Strong)
these high-risk groups, consultation with a pediatric infec- • Competency in the pediatric ear exam, which
tious disease specialist can be helpful. includes the general approach, visualization of the
TM, pneumatic otoscopy, and cerumen removal, is
Complications
critical to the appropriate diagnosis of AOM.8,15
Early diagnosis and management of AOM is important
(Strength of Recommendation: Strong)
because if it is left untreated, more serious complications
can occur. In some cases, the infection can spread to the sur- • Engaging the parents or caregivers in shared deci-
rounding tissues and cause mastoiditis, which can be very sion-making is important for patients with AOM.
painful and require surgical treatment. Another major com- Supportive measures including the use of antipy-
plication, although less common, is meningitis. AOM can retics, and indications for follow-up should be
also cause the eardrum to perforate, leading to drainage of discussed with the parents and caregivers.14,20
fluid from the ear. In rare cases, AOM can lead to hearing (Strength of Recommendation: Moderate)
loss, which can have long-term effects on a child’s develop-
ment and ability to learn.

Primary and Secondary Prevention

Take the quiz! Scan this QR code to take the quiz,
Pediatricians should recognize the preventable risk factors of access the references, and view and save images
AOM. Breastfeeding in the first 6 months of life has been and tables (available March 1, 2025).
shown to be protective against AOM.34,35 In addition to

Vol. 46 No. 3 M A R C H 2 0 2 5 145

Downloaded from http://publications.aap.org/pediatricsinreview/article-pdf/46/3/139/1774529/pedsinreview.2023006216.pdf

by New York City Health & Hospitals, Juan Sosa
 PIR QUIZ

1. A 19-month-old boy is brought to the clinic by his parents because they

noticed him to be fussy and pulling at his right ear. He attends daycare, and
he has had multiple ear infections since he started daycare, which were
treated with antibiotics. He was born at 34 weeks gestation to a G10 mother
with no perinatal complications. His immunizations are up to date for his age.
His height and weight are at the fifth percentile, and his head circumference
is at the seventh percentile. His growth rate and development have been
normal, and parents are both 5 0 6” tall. The father smokes cigarettes mostly
outside. There is no family history of allergies. There is a pet parrot in the
household. In addition to daycare attendance, which of the following is an
additional risk factor that most likely predisposes this patient to recurrent REQUIREMENTS: Learners can
acute otitis media episodes? take Pediatrics in Review quizzes
and claim credit online only at:
A. Borderline prematurity http://pedsinreview.org.
B. Having a parrot as a pet
To successfully complete 2025
C. Having no older siblings at home
Pediatrics in Review articles for
D. Low mid-parental height AMA PRA Category 1 Credit™,
E. Passive smoking exposure learners must demonstrate a
minimum performance level of
2. The patient in the above vignette was diagnosed on physical examination
60% or higher on this
with right purulent otitis media. Among the following pathogens, which assessment. If you score less than
is the most likely cause of acute otitis media in this patient? 60% on the assessment, you will
be given additional opportunities
A. Hemophilus influenzae
to answer questions until an
B. Nonvaccine serotypes of Streptococcus pneumoniae overall 60% or greater score is
C. Respiratory viruses achieved.
D. Staphylococcus aureus
E. Streptococcus pyogenes This journal-based CME activity is
available through Dec. 31, 2027,
3. A 3-year-old girl is brought to the clinic by her parents because of a 2-day however, credit will be recorded
history of rhinorrhea and fever. This morning, she started to complain of in the year in which the learner
a left earache and has had a decrease in activity and appetite. There are sick completes the quiz.

contacts in daycare. The patient is otherwise healthy. She takes no

medications and is up to date on her immunizations. There are no known
drug allergies and no previous history of recent illnesses. Physical
examination shows red tympanic membranes with poor mobility bilaterally
on insufflation (more so on the left than the right). Which of the following is
the most appropriate antibiotic regimen in this patient? 2025 Pediatrics in Review is
approved for a total of 30
A. Azithromycin 10 mg/kg on day 1 then 5 mg/kg on days 2–5 Maintenance of Certification
B. Amoxicillin 90 mg/kg/d for 7 days (MOC) Part 2 credits by the
C. Amoxicillin 90 mg/kg/d for 10 days American Board of Pediatrics
(ABP) through the AAP MOC
D. Amoxicillin-clavulanic acid 90 mg/kg/d for 7 days
Portfolio Program. Pediatrics in
E. Amoxicillin-clavulanic acid 90 mg/kg/d for 10 days Review subscribers can claim up
to 30 ABP MOC Part 2 points
upon passing 30 quizzes (and
claiming full credit for each quiz)
per year. Subscribers can start
claiming MOC credits as early as
October 2025. To learn how to
claim MOC points, go to: https://
publications.aap.org/journals/
pages/moc-credit.

146 Pediatrics in Review

Downloaded from http://publications.aap.org/pediatricsinreview/article-pdf/46/3/139/1774529/pedsinreview.2023006216.pdf

by New York City Health & Hospitals, Juan Sosa
 4. A 2-year-old boy is brought to the clinic by his parents because of a 2-day
history of high fevers up to 39°C associated with clear rhinorrhea, fussiness,
bilateral redness of the eyes, decreased activity, and decreased appetite.
He has had recurrent episodes of otitis media for the past 12 months since
he started daycare for which he has been on multiple antibiotic courses. His
immunizations are delayed due to “being sick all the time in the past year.”
His last vaccines were given when aged 12 months. He is diagnosed with
bilateral otitis and conjunctivitis. The parents are reluctant to start another
antibiotics course. The clinician explains to the parents that, if untreated,
otitis media can lead to serious potential complications. Among the following,
which is the most common potential acute complication of untreated otitis
media in this child?
A. Acute mastoiditis
B. Epidural abscess
C. Lateral sinus thrombosis
D. Meningitis
E. Stroke
5. In children who are diagnosed with recurrent episodes of otitis media, which
of the following is the most likely potential long-term complication of
recurrent acute otitis media that can affect a child’s development and ability
to learn?
A. Acute perforation of tympanic membrane
B. Development of cholesteatomas
C. Episodes of acute otalgia
D. Fluctuating or persistent hearing loss
E. Mastoiditis

Vol. 46 No. 3 M A R C H 2 0 2 5 147

Downloaded from http://publications.aap.org/pediatricsinreview/article-pdf/46/3/139/1774529/pedsinreview.2023006216.pdf

by New York City Health & Hospitals, Juan Sosa