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  • Otalgia.

  • Purulent fluid of the middle ear.

  • Erythema and hypomobility of tympanic membrane.

General Considerations

Acute otitis media is a bacterial infection of the mucosally lined, air-containing spaces of the middle ear. Purulent material may extend to pneumatized mastoid air cells and petrous apex of the lateral skull base. Acute otitis media is usually precipitated by a viral upper respiratory tract infection that causes eustachian tube obstruction. This results in accumulation of fluid and mucus, which becomes secondarily infected by bacteria. The most common pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes.

Clinical Findings

Acute otitis media is most common in infants and children, although it may occur at any age. Presenting symptoms and signs include otalgia, aural pressure, decreased hearing, and often fever. The typical physical findings are erythema and decreased mobility of the tympanic membrane (Figure 8–2). Occasionally, bullae will appear on the tympanic membrane.

Figure 8–2.

Acute otitis media with effusion of right ear, with multiple air-fluid levels visible through a translucent, slightly retracted, nonerythematous tympanic membrane. (Used, with permission, from Frank Miller, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H. The Color Atlas of Family Medicine, 2nd ed. McGraw-Hill, 2013.)

Rarely, when middle ear empyema is severe, the tympanic membrane bulges outward. In such cases, tympanic membrane rupture is imminent. Rupture is accompanied by a sudden decrease in pain, followed by the onset of otorrhea. With appropriate therapy, spontaneous healing of the tympanic membrane occurs in most cases. Acute mastoiditis results from an infection extending from the middle ear to the mastoid air cells. It is diagnosed by pain, postauricular erythema, and occasionally proptosis of the auricle. Frank swelling over the mastoid bone or the association of cranial neuropathies or central findings indicates severe disease requiring urgent care. Evaluation includes imaging, such as CT, to determine presence of “coalescence” of air cells and associated soft-tissue abscess.


The treatment of acute otitis media is specific antibiotic therapy, often combined with nasal decongestants. The first-choice antibiotic is amoxicillin 1 g orally every 8 hours for 5–7 days. Alternatives (useful in resistant cases) are amoxicillin-clavulanate 875/125 mg or 2 g/125 mg ER every 12 hours for 5–10 days; or cefuroxime 500 mg or cefpodoxime 200 mg orally every 12 hours for 5–7 days. Recurrent acute otitis media may be managed with long-term antibiotic prophylaxis. Single daily oral doses of sulfamethoxazole (500 mg) or amoxicillin (250 or 500 mg) are given over a period of 1–3 months. Failure of this regimen to control infection is an indication for insertion of ventilating tubes.

Surgical drainage of the middle ear (myringotomy), debridement of the mastoid ...

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