otitis media clinical presentation

7/28/2019 Otitis Media Clinical Presentation

1/14


emedicine.medscape.com/article/994656-clinical 1/14

Otitis Media Clinical Presentation

Author: Muhammad Waseem, MD, MS; Chief Editor: Glenn C Isaacson, MD, FACS, FAAP more...

Updated: Apr 1, 2013

History

Suspect acute otitis media (AOM), with or without effusion, in children with a history of the following

symptoms:

Head and neck

Otalgia: Young children may exhibit signs of otalgia by pulling on the affected ear or ears or

pulling on the hair. Otalgia apparently occurs more often when the child is lying down (eg,

during the night, during nap time), which may be due to increased ETD when the child is in a

recumbent position.

Otorrhea: Discharge may come from the middle ear through a recently perforated TM, through

a preexisting TT, or through another perforation. For trauma patients, excluding a basilar skull

fracture with associated cerebrospinal fluid (CSF) otorrhea is important.

Headache

Concurrent or recent URI symptoms (eg, cough, rhinorrhea, sinus congestion)

General

Two thirds of children with AOM have a history of fever, although fevers greater than 40C are

uncommon and may represent bacteremia or other complications.

Irritability may be the sole early symptom in a young infant or toddler.

A history of lethargy, although nonspecific, is a sensit ive marker for sick children and should

not be dismissed.GI tract: Symptoms include anorexia, nausea, vomiting, and diarrhea.

OME often follows an episode of AOM. Consider OME in patients with recent AOM in whom the history

includes any of the following symptoms:

Hearing loss: Most young children cannot provide an accurate history. Parents, caregivers, or

teachers may suspect a hearing loss or describe the child as inattentive.

Tinnitus: This is possible, although it is an unusual complaint from a child.

Vertigo: Although true vertigo (ie, room-spinning dizziness) is a rare complaint in uncomplicated

AOM or OME, parents may report some unsteadiness or clumsiness in a young child with AOM.

Otalgia: Intermittent otalgia tends to worsen at night.

OM treatment widely varies based on the duration of symptoms, past therapeutic failures, and severity of

current symptoms.

Exposure to environmental risk factors is another important aspect of the history and includes the following:Passive exposure (ie, secondhand) to tobacco smoke

Group daycare attendance

Seasonality: AOM prevalence is much higher in winter and early spring than in summer and early

fall.

Medscape Reference

Reference

News

Reference

Education

MEDLINE
http://www.medscape.com/resource/headachehttp://reference.medscape.com/http://reference.medscape.com/http://emedicine.medscape.com/article/961169-overviewhttp://www.medscape.com/resource/headache


2/14



Supine bottle feeding (ie, bottle propping)

Physical

Pneumatic otoscopy remains the standard examination technique for patients with suspected OM. When

performed correctly, this technique is 90% sensitive and 80% specific for diagnosis of AOM, and findings are more

accurate than with myringotomy. Proper pneumatic otoscopy technique is crucial to distinguish AOM from OME

because recommended therapies for these entities are significantly different. Studies show that most practitioners

improperly perform otoscopic examinations. Almost one half of physicians never use pneumatic compression ofthe TM during routine otoscopic examination, and almost 30% use otoscopes with inadequate light sources.

Tympanometry, acoustic reflectometry, and audiometry are important adjunctive techniques with which to evaluate

patients with MEE.

In addition to a carefully documented examination of the external ear and TM, examining the entire head and neck

region of patients with suspected OM is important. Several congenital syndromes, craniofacial anomalies, and

systemic diseases have increased incidence associated with OM, including cleft palate, Down syndrome,

Treacher Collins syndrome (ie, mandibulofacial dysotosis), hemifacial microsomia, diabetes mellitus, human

immunodeficiency virus (HIV) infection, and many types of mucopolysaccharidosis.

Below are examination techniques used in the diagnosis of OM.

Pneumatic otoscopy examination

Under direct visualization, first remove any cerumen, which causes a limited and sometimes inaccurate

view of the TM and inaccurate and confusing results on tympanometry and audiometry.

To move the TM, the ear speculum must create an air seal against the external auditory canal (EAC), which

is seldom possible with a standard disposable speculum. All otoscope manufacturers sell inexpensive

cuffed ear speculums to perform insufflation. A rubber sleeve over the speculum may reduce patient

discomfort during the examination. Usually, the TM is in the neutral position (ie, neither retracted nor

bulging), pearly gray, translucent, and unperforated. It responds briskly to posit ive and negative pressure,

indicating an air-filled space. Many older texts emphasize a TM "light reflex" in an otherwise normal ear.

Because this reflex may be absent in entirely normal ears and present in ears with MEE, the light reflexdoes not help confirm or exclude an OM diagnosis.

Every examination should include an evaluation and description of the following 4 TM characteristics:

Color

A normal TM is a translucent pale gray.

An opaque yellow or blue TM is consistent with MEE.

Dark red indicates a recent trauma or blood behind the TM.

A dark pink or lighter red TM is consistent with AOM or hyperemia of the TM caused by

crying, coughing, or nose blowing.

Color of the eardrum is less important diagnostically than its position and mobility. Redness

of the TM alone does not necessarily suggest AOM because crying, removal of cerumen with

associated irritation of the auditory canal, coughing, nose blowing, and fever can all cause

redness of the eardrum without a middle ear infection. Note that most children cry when theirears are examined.

A study of 85 infants showed that the otoscopic finding most predictive of AOM was a poorly

mobile, bulging, yellow, and opacified TM. However, this appearance was noted in only 19%

of patients. In another analysis, a slightly red TM in a normal position and with normal

mobility had a predictive value of only 7% for AOM.

Position: The position of the TM (ie, bulging, retracted, neutral, full) is key to differentiating AOM

from OME.

In AOM, the TM is usually bulging.

In OME, the TM is typically retracted or in the neutral position.

Mobility: Abnormal movement of the TM during pneumatic otoscopy can suggest various conditions

or disorders.

Movement during negative pressure only suggests ETD.

A TM that moves only slightly with both positive and negative pressure applied indicates the

probable presence of middle ear fluid.

No movement occurs with a TM perforation or a TT.

Studies show that the most consistent physical finding in patients with OME is impaired
http://emedicine.medscape.com/article/965086-overviewhttp://emedicine.medscape.com/article/946143-overviewhttp://emedicine.medscape.com/article/943216-overviewhttp://emedicine.medscape.com/article/995535-overview


3/14



mobility of the TM during pneumatic otoscopy. Pay special attention to movement of retracted

segments of the TM because immobility of these sections may indicate middle ear

cholesteatoma in the retraction pockets.

Perforation

Single perforations are most common, but some patients may have multiple perforations.

Note the location and cause of the perforation.

Perforations in the posterosuperior quadrant, which are the most difficult to detect, are

important because they occasionally are associated with cholesteatoma.

Pus or other fluid may drain through a perforation.

Multiple perforations and otorrhea that does not yield pathogens on culture may indicatetuberculosis.

Adjunctive screening techniques for OM: Adjunctive techniques help identify patients with asymptomatic OME,

which may comprise 10% of cases.

Tympanometry (ie, impedance audiometry), the most commonly used adjunctive technique, measures

changes in acoustic impedance of the TM/middle ear system with air pressure changes in the EAC.

Current recommendations call for screening tympanometry at the beginning of school and 1 year

later to identify children aged 4-6 years with asymptomatic OME.

Tympanometry screening has a high degree of sensitivity (>90%) but is not specific for OME.

The test may yield false-positive results in children with a retracted TM or a thickened TM without

effusion. Screening tests may also yield invalid results in children who have cerumen obstructing theexternal canal or who are crying during the examination.

Middle ear pressure more than 200 daPa or a flat tympanometric curve is classified as a failure.

Further physician evaluation is indicated in a child in whom tympanometry screening fails in both

ears and who has at least a 20-dB hearing loss at 1, 2, or 4 kHz.

After 2 months, retest any child in whom tympanometry screening fails in one ear and hearing loss

occurs (>20 dB). Also retest children in whom tympanometry screening fails in both ears, even

without marked hearing loss (ie, < 20 dB). A second screening failure should lead to physician

evaluation. Assess the child's hearing, speech, and language and immediately start therapy to

correct deficits.

Acoustic reflectometry uses an acoustic otoscope to measure reflected sound from the TM; the louder the

reflected sound, the greater the likelihood of an MEE. The breakpoint is defined as the level of soundreflectivity that correlates with the presence of MEE.

Acoustic reflectometry is rapid and easy to perform. Among its advantages over tympanometry is

that an airtight seal of the EAC is unnecessary and that the test is unaffected by a crying patient or

the presence of cerumen in the EAC.

Despite these advantages, acoustic reflectometry has not been widely accepted by

otolaryngologists because of the difficulty in setting standards to interpret test results.

No accepted breakpoint standards have been established, so sensitivity and specificity vary

according to the breakpoints set for each study. A low breakpoint leads to high sensitivity but low

specificity. A high breakpoint leads to higher specificity but lower sensitivity.

Causes

A mult itude of host, infectious, allergic, and environmental factors contribute to OM development.

Host factors

Immune system: The immature immune systems of infants or the impaired immune systems of

patients with congenital immune deficiencies, HIV infection, or diabetes may be involved in the

development of OM. OM is an infectious disease that prospers in an environment of decreased

immune defenses. The interplay between pathogens and host immune defense plays a role in

disease progression. Patel et al (2009) found higher interleukin (IL)6 levels in patients with OM who

also had influenza and adenoviral infections, whereas IL-1-beta (IL-1-beta) levels were higher in

patients who developed OM following URI.[2] In another study, Skovbjerg et al (2009) found that

middle ear effusions with culturable pathogenic bacteria were associated with higher levels of IL-1-beta, IL-8, and IL-10 than sterile effusions.[3]

Familial (genetic) predisposition: Although familial clustering of OM has been demonstrated in

studies that examined genetic associations of OM, separating genetic factors from environmental

influences has been difficult. No specific genes have been linked to OM susceptibility. As with most

disease processes, effects of environmental exposures on genetic expression probably play an


4/14



important role in OM pathogenesis.

Mucins: The role of mucins in OME has been described. Mucins are responsible for gel-like

properties of mucus secretions. The middle ear mucin gene expression is unique compared with the

nasopharynx. Abnormalities of this gene expression, especially upregulation ofMUC5B in the ear,

may have a predominant role in OME.

Anatomic abnormality: Children with anatomic abnormalities of the palate and associated

musculature, especially the tensor veli palantini, exhibit marked ETD and have higher risk for OM.

Specific anomalies that correlate with high prevalence of OM include cleft palate, Crouzon syndrome

orApert syndrome, Down syndrome, and Treacher Collins syndrome.

Physiologic dysfunction: Abnormalities in the physiologic function of the ET mucosa, includingciliary dysfunction and edema, increase the risk of bacterial invasion of the middle ear and the

resultant OME. Children with cochlear implants have a high incidence of OM, especially chronic OM

and cholesteatoma formation. One study described a relationship between laryngopharyngeal reflux

and chronic OM (COM); the authors concluded that reflux work-up should be performed as part of

COM investigations, and, if reflux is confirmed, reflux treatment should be initiated in addition to

treatment of primary disease.[4]

Vitamin A deficiency is associated with pediatric upper respiratory infections and AOM.

Obesity has been linked to an increased incidence of OM, although the causal factor is unknown.

Speculations include alteration of intrinsic cytokine profile, increased gastroesophageal reflux with

alterations of the oral flora, and/or fat accumulation; all of these have been linked with an increased

incidence of OM. Conversely, OM may increase the risk of obesity by altering the taste buds.[5]

Infectious factors

Bacterial pathogens

The most common bacterial pathogen in AOM is Streptococcus pneumoniae, followed by

nontypeable Haemophilus influenzae and Moraxella catarrhalis. These 3 organisms are

responsible for more than 95% of all AOM cases with a bacterial etiology.

In infants younger than 6 weeks, gram-negative bacilli (eg, Escherichia coli, Klebsiella

species, and Pseudomonas aeruginosa) play a much larger role in AOM, causing 20% of

cases. S pneumoniae and H influenzae are also the most common pathogens in this age

group. Staphylococcus aureus has also been found as a pathogen in this age group in some

studies, but more recent studies suggest that the flora in these young infants may be that of

usual AOM in children older than 6 weeks.

Many experts had proposed that the MEE associated with OME was sterile because culturesof middle ear fluid obtained by tympanocentesis often did not grow bacteria. This view is

changing as newer studies show 30-50% incidence of positive results in middle ear bacterial

cultures in patients with chronic MEE. These cultures grow a wide range of aerobic and

anaerobic bacteria; S pneumoniae, H influenzae, M catarrhalis, and group A streptococci are

the most common.

M catarrhalis induced AOM differs from AOM caused by other bacterial pathogens in several

ways. It is characterized by higher a proportion of mixed infections, younger age at the time

of diagnosis, lower risk of spontaneous perforation of the tympanic membrane, and an

absence of mastoiditis.[6]

Further evidence for the presence of bacteria in the MEE of patients with OME was provided

by studies using polymerase chain reaction (PCR) assay to detect bacterial DNA in MEEsamples that were determined to be sterile using standard bacterial culture techniques. In

one such study using PCR assay, 77.3% of the MEE samples had positive results for one or

more common AOM pathogens (eg, S pneumoniae, H influenzae, M catarrhalis).

In chronic suppurative OM, the most frequently isolated organisms include P aeruginosa, S

aureus, Corynebacterium species, and Klebsiella pneumoniae. An unanswered question is

whether these pathogens invade the middle ear from the nasopharynx via the ET (as do the

bacteria responsible for AOM) or whether they enter through the perforated TM or a TT from

the EAC.

The role ofHelicobacter pyloriin children with OME has been increasingly recognized.

Evidence that this agent might be responsible for OME comes from its isolation from middle

ear and tonsillar and adenoidal tissue in patients with OME.

Alloiococcus otitidis is a newly recognized species of gram-positive bacterium that has beenrecently discovered as a pathogen associated with OME.[7, 8] This organism is the most

frequent bacterium in AOM, as well as in OME. It has also been detected in patients who had

been treated with antibiotics, such as beta-lactams or erythromycin, suggesting that these

agents may not be sufficiently effective to eliminate this organism. Further investigation is
http://emedicine.medscape.com/article/1982450-overviewhttp://emedicine.medscape.com/article/941723-overviewhttp://emedicine.medscape.com/article/942989-overview


5/14



needed to reveal the clinical role of the organism in OM.

Viral pathogens

Because acute viral URI is a prominent risk factor for AOM development, most investigators have

suspected a role for respiratory viruses in AOM pathogenesis.

Many studies have substantiated this suspicion by showing how certain respiratory viruses can

cause inflammatory changes to the respiratory mucosa that lead to ETD, increased bacterial

colonization and adherence, and, eventually, AOM. Studies have also shown that viruses can alter

the host-immune response to AOM, thereby contributing to prolonged middle ear fluid production and

development of chronic OME.

The viruses most commonly associated with AOM are respiratory syncytial virus (RSV), influenzaviruses, parainfluenza viruses, rhinovirus, and adenovirus.

Human parechovirus 1 (HPeV1) infection is associated with OM and cough in pediatric patients. [9]

OM developed in 50% of 3-month follow-up periods that yielded evidence of HPeV1 infection but in

only 14% of the HPeV1-negative periods; in recurring OM, the middle ear fluid samples were positive

for HPeV in 15% of episodes.

Factors related to allergies

The relationship between allergies and OM remains unclear. In children younger than 4 years, the

immune system is still developing, and allergies are unlikely to play a role in recurrent AOM in this

age group. Although much evidence suggests that allergies contribute to the pathogenesis of OM in

older children, extensive evidence refutes the role of allergies in the etiology of middle ear disease.

The following is a brief list of evidence for and against the etiologic role of allergy in OM:Many patients with OM have concomitant allergic respiratory disease (eg, allergic rhinitis,

asthma).

Many patients with OM have positive results to skin testing or radioallergosorbent testing

(RAST).

Although mast cells are found in the middle ear mucosa, most studies fail to show significant

levels of immunoglobulin E (IgE) or eosinophils in the MEE of patients with OM.

OM is most common in the winter and early spring, yet most major allergens (eg, tree and

grass pollens) peak in the late spring and early fall.

Most patients with concomitant OM and allergy show no marked improvement in middle ear

disease with aggressive allergy management, despite marked improvements to nasal and

other allergy-related symptoms.

Environmental factorsInfant feeding methods

Many studies report that breastfeeding protects infants against OM. The most recent and

best of these studies indicates that this benefit is evident only in children who are breastfed

exclusively for the first 3-6 months of life. Breastfeeding of this duration reduces the incidence

of OM by 13%.

The protective effects of breastfeeding for the first 3-6 months persist 4-12 months after

breastfeeding ceases, possibly because delaying onset of the first OM episode reduces

recurrence of OM in these children.

Passive smoke exposure

Many studies have shown a direct relationship between passive smoke exposure and risk of

middle ear disease.

A recent systematic review of 45 publications dealing with OM and parental smoking showed

pooled odds ratios of 1.48 (95% confidence interval [CI] of 1.08-2.04) for recurrent OM, 1.38

(95% CI of 1.23-1.55) for MEE, and 1.3 (95% CI of 1.3-1.6) for AOM.[10]

Group daycare attendance

Daycare centers create close contact among many children, which increases the risks of

respiratory infection, nasopharyngeal colonization with pathogenic microbes, and OM.

Many researchers have used meta-analysis to confirm that exposure to other young children

(including siblings) in group daycare settings is a major risk factor for OM. [11]A meta-

analysis reported that care outside the home conferred a 2.5-fold risk for OM. Other critical

reviews of studies on OM and group childcare show heightened odds ratios of 1.6-4.0:1 for

center care versus home care.

Children who attend daycare centers frequently acquire antibacterial-resistant organisms intheir nasopharynx, leading to AOM that may be refractory to antibacterial treatment.

American Academy of Pediatrics and American Academy of Family Physicians' guidelines

recommend high-dose amoxicillin/clavulanic acid as the antibiotic of choice in the treatment

of AOM in children who attend daycare.
http://emedicine.medscape.com/article/971488-overview


6/14



Socioeconomic factors: Socioeconomic status encompasses many independent factors that affect both the

risk of OM and the likelihood that OM will be diagnosed.[12]

In general, lower socioeconomic status confers higher risk for environmental exposure to parental

smoking, bottle-feeding, crowded group daycare, crowded living conditions, and viruses and bacterial

pathogens.

Compared with children from middle-income and high-income families, children from lower

socioeconomic groups use health care resources less frequently, which decreases the likelihood

that OM cases will be diagnosed.

Contributor Information and DisclosuresAuthor

Muhammad Waseem, MD, MS Associate Professor of Emergency Medicine in Clinical Pediatrics, Weill

Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, Lincoln Medical

and Mental Health Center

Muhammad Waseem, MD, MS is a member of the following medical societies:American Academy of

Pediatrics,American College of Emergency Physicians,American Heart Association, andAmerican Medical

Association

Disclosure: Nothing to disclose.

Coauthor(s)

Muhammad Aslam, MD Assistant Professor of Pediatrics, Harvard Medical School; Staff Physician, Division

of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital

Muhammad Aslam, MD is a member of the following medical societies: American Academy of Pediatrics,

American Medical Association,American Medical Association, Massachusetts Medical Society, and Southern

Medical Association


Specialty Editor Board

Orval Brown, MD Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and NeckSurgery, University of Texas Southwestern Medical Center at Dallas

Orval Brown, MD is a member of the following medical societies:American Academy of Otolaryngology-Head

and Neck Surgery,American Academy of Pediatrics,American Bronchoesophagological Association,

American College of Surgeons,American Medical Association,American Society of Pediatric Otolaryngology,

Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and

Neck Surgeons


Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of

Pharmacy; Editor-in-Chief, Medscape Drug Reference


Alan D Murray MD, Pediatric Otolaryngologist, ENT for Children; Full-Time Staff, Medical City Dallas

Children's Hospital; Consulting Staff, Department of Otolaryngology, Medical Center of Lewisville, Children's

Medical Center at Dallas, Cook Children's Medical Center; Full-Time Staff, Texas Pediatric Surgery Center,

Cook Children's Pediatric Surgery Center Plano

Alan D Murray is a member of the following medical societies: Alpha Omega Alpha,American Academy of

Otolaryngology-Head and Neck Surgery,American Academy of Pediatrics,American College of Surgeons,

American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and

Texas Medical Association


Daniel Rauch, MD, FAAP Director, Pediatric Hospitalist Program, Associate Professor, Department of
http://www.texmed.org/http://www.sentac.org/http://www.aspo.us/http://www.facs.org/http://www.aap.org/http://www.entnet.org/http://www.alphaomegaalpha.org/http://www.suo-aado.org/SUO/index.htmlhttp://www.sentac.org/http://www.aspo.us/http://www.ama-assn.org/http://www.facs.org/http://www.abea.net/http://www.aap.org/http://www.entnet.org/http://www.sma.org/http://www.massmed.org/AM/Template.cfm?Section=Homehttp://www.ama-assn.org/http://www.ama-assn.org/http://www.aap.org/http://www.ama-assn.org/http://www.americanheart.org/presenter.jhtml?identifier=1200000http://www.acep.org/http://www.aap.org/


7/14



Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association,

American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Glenn C Isaacson, MD, FACS, FAAP Professor of Otolaryngology-Head and Neck Surgery and Pediatrics,

Temple University School of Medicine

Glenn C Isaacson, MD, FACS, FAAP is a member of the following medical societies:American Academy of

Otolaryngology-Head and Neck Surgery,American Academy of Pediatrics,American Bronchoesophagological

Association,American College of Surgeons,American Laryngological Rhinological and Otological Society ,

American Society of Pediatric Otolaryngology, and Society of University Otolaryngologists-Head and Neck

Surgeons

Disclosure: Covidien Honoraria Consulting

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors,

Michael Jones, MD, David Malis, MD, and Leslie Wilson, MD, to the development and writing of this article.

References

1. Fireman P. Otit is media and eustachian tube dysfunction: connection to allergic rhinitis. J Allergy Clin

Immunol. Feb 1997;99(2):S787-97. [Medline].

2. Patel JA, Nair S, Revai K, Grady J, Chonmaitree T. Nasopharyngeal acute phase cytokines in viral upper

respiratory infection: impact on acute otitis media in children. Pediatr Infect Dis J. Nov 2009;28(11):1002-

7. [Medline].

3. Skovbjerg S, Roos K, Nowrouzian F, Lindh M, Holm SE, Adlerberth I, et al. High cytokine levels in

perforated acute otit is media exudates containing live bacteria. Clin Microbiol Infect. Oct 14 2009;

[Medline].

4. Bercin S, Kutluhan A, Yurttas V, Yalciner G, Bozdemir K, Sari N. Evaluation of laryngopharyngeal reflux

in patients with suspected laryngopharyngeal reflux, chronic otitis media and laryngeal disorders. Eur

Arch Otorhinolaryngol. May 21 2008;[Medline].

5. Lee SK, Yeo SG. Relationship between pediatric obesity and otitis media with effusion. Curr Allergy

Asthma Rep. Nov 2009;9(6):465-72. [Medline].

6. Broides A, Dagan R, Greenberg D, Givon-Lavi N, Leibovitz E. Acute otitis media caused by Moraxella

catarrhalis: epidemiologic and clinical characteristics. Clin Infect Dis. Dec 1 2009;49(11):1641-7.

[Medline].

7. Harimaya A, Takada R, Hendolin PH, et al. High incidence of Alloiococcus otitidis in children with otitis

media, despite treatment with antibiotics. J Clin Microbiol. Mar 2006;44(3):946-9. [Medline].

8. de Miguel Martinez I, Macias AR. Serous otitis media in children: implication of Alloiococcus otit idis. Otol

Neurotol. Jun 2008;29(4):526-30. [Medline].

9. Tauriainen S, Oikarinen S, Taimen K, et al. Temporal relationship between human parechovirus 1 infection

and otitis media in young children. J Infect Dis. Jul 1 2008;198(1):35-40. [Medline].

10. Strachan DP, Cook DG. Health effects of passive smoking. 4. Parental smoking, middle ear disease and

adenotonsillectomy in children. Thorax. Jan 1998;53(1):50-6. [Medline].

11. Greenberg D, Hoffman S, Leibovitz E, Dagan R. Acute otitis media in children: association with day care

centers - antibacterial resistance, treatment, and prevention. Paediatr Drugs. 2008;10(2):75-83. [Medline].

12. Elden LM, Coyte PC. Socioeconomic impact of otitis media in North America. J Otolaryngol. 1998;27

Suppl 2:9-16. [Medline].
http://reference.medscape.com/medline/abstract/9800635http://reference.medscape.com/medline/abstract/18345717http://reference.medscape.com/medline/abstract/9577522http://reference.medscape.com/medline/abstract/18462136http://reference.medscape.com/medline/abstract/18418283http://reference.medscape.com/medline/abstract/16517881http://reference.medscape.com/medline/abstract/19886799http://reference.medscape.com/medline/abstract/19814920http://reference.medscape.com/medline/abstract/18493783http://reference.medscape.com/medline/abstract/19832705http://reference.medscape.com/medline/abstract/19859015http://reference.medscape.com/medline/abstract/9042072http://www.suo-aado.org/SUO/index.htmlhttp://www.aspo.us/http://www.triological.org/http://www.facs.org/http://www.abea.net/http://www.aap.org/http://www.entnet.org/http://www.hospitalmedicine.org/AM/Template.cfm?Section=Homehttp://www.aap.org/http://www.ambpeds.org/site/index.htm


8/14



13. Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: management and surveillance in an era of

pneumococcal resistance--a report from the Drug-resistant Streptococcus pneumoniae Therapeutic

Working Group. Pediatr Infect Dis J. Jan 1999;18(1):1-9. [Medline].

14. American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and

management of acute otitis media. Pediatrics . May 2004;113(5):1451-65. [Medline].

15. Arguedas A, Dagan R, Leibovitz E, et al. A mult icenter, open label, double tympanocentesis study of high

dose cefdinir in children with acute otitis media at high risk of persistent or recurrent infection. Pediatr

Infect Dis J. Mar 2006;25(3):211-8. [Medline].

16. Rovers MM, Glasziou P, Appelman CL, Burke P, McCormick DP, Damoiseaux RA. Antibiotics for acute

otitis media: a meta-analysis with individual patient data. Lancet. Oct 21 2006;368(9545):1429-35.

[Medline].

17. Chandler SM, Garcia SM, McCormick DP. Consistency of diagnostic criteria for acute otitis media: a

review of the recent literature. Clin Pediatr (Phila). Mar 2007;46(2):99-108. [Medline].

18. Vernacchio L, Vezina RM, Mitchell AA. Management of acute otitis media by primary care physicians:

trends since the release of the 2004 American Academy of Pediatrics/American Academy of Family

Physicians clinical practice guideline. Pediatrics. Aug 2007;120(2):281-7. [Medline].

19. Klein JO. Review of consensus reports on management of acute otit is media. Pediatr Infect Dis J. Dec1999;18(12):1152-5. [Medline].

20. Noel GJ, Blumer JL, Pichichero ME, Hedrick JA, Schwartz RH, Balis DA, et al. A Randomized

Comparative Study of Levofloxacin Versus Amoxicillin/Clavulanate for Treatment of Infants and Young

Children With Recurrent or Persistent Acute Otitis Media. Pediatr Infect Dis J. Jun 2008;27(6):483-489.

[Medline].

21. Fischer T, Singer AJ, Lee C, Thode HC Jr. National trends in emergency department antibiotic prescribing

for children with acute otitis media, 1996-2005.Acad Emerg Med. Dec 2007;14(12):1172-5. [Medline].

22. Stool SE, Berg AO. Otitis media with effusion in young children. Clinical practice guideline number 12.

1994.

23. Rosenfeld RM. An evidence-based approach to treating otit is media. Pediatr Clin North Am. Dec

1996;43(6):1165-81. [Medline].

24. Bluestone CD. Role of surgery for otitis media in the era of resistant bacteria. Pediatr Infect Dis J. Nov

1998;17(11):1090-8; discussion 1099-100. [Medline].

25. [Best Evidence] Prymula R, Peeters P, Chrobok V, et al. Pneumococcal capsular polysaccharides

conjugated to protein D for prevention of acute otit is media caused by both Streptococcus pneumoniae

and non-typable Haemophilus influenzae: a randomised double-blind efficacy study. Lancet. Mar 4

2006;367(9512):740-8. [Medline].

26. Coker TR, Chan LS, Newberry SJ, Limbos MA, Suttorp MJ, Shekelle PG, et al. Diagnosis, MicrobialEpidemiology, and Antibiotic Treatment of Acute Otitis Media in Children: A Systematic Review. JAMA.

Nov 17 2010;304(19):2161-2169. [Medline].

27. Foshee WS, Steele RW. Should prophylactic antibiotics be used for the otitis-media-prone child?. Pediatr

Infect Forum. 2000;2:2-7.

28. ACIP. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization

Practices (ACIP). MMWR Recomm Rep. Apr 30 1999;48(RR-4):1-28. [Medline].

29. Adderson EE. Preventing otitis media: medical approaches. Pediatr Ann. Feb 1998;27(2):101-7.

[Medline].

30. Adeli M, Bender MJ, Sheridan MJ, Schwartz RH. Antibiotics for simple upper respiratory tract infections:

a survey of academic, pediatric, and adult clinical allergists. Ann Allergy Asthma Immunol. Apr

2008;100(4):377-83. [Medline].

31. Aliphas A, Prufer N, Grundfast KM. Emerging therapies for the treatment and prevention of otitis media.
http://reference.medscape.com/medline/abstract/18450125http://reference.medscape.com/medline/abstract/9523298http://reference.medscape.com/medline/abstract/10366138http://reference.medscape.com/medline/abstract/21081729http://reference.medscape.com/medline/abstract/16517274http://reference.medscape.com/medline/abstract/9850004http://reference.medscape.com/medline/abstract/8973506http://reference.medscape.com/medline/abstract/18045893http://reference.medscape.com/medline/abstract/18449063http://reference.medscape.com/medline/abstract/10608648http://reference.medscape.com/medline/abstract/17671053http://reference.medscape.com/medline/abstract/17325082http://reference.medscape.com/medline/abstract/17055944http://reference.medscape.com/medline/abstract/16511382http://reference.medscape.com/medline/abstract/15121972http://reference.medscape.com/medline/abstract/9951971


9/14



Expert Opin Emerg Drugs. May 2006;11(2):251-64. [Medline].

32. [Guideline] American Academy of Family Physicians; American Academy of Otolaryngology-Head and

Neck Surgery; American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Otitis

media with effusion. Pediatrics . May 2004;113(5):1412-29. [Medline].

33. Aronovitz GH. Antimicrobial therapy of acute otit is media: review of treatment recommendations. Clin

Ther. Jan 2000;22(1):29-39. [Medline].

34. Asher E, Dagan R, Greenberg D, Givon-Lavi N, Libson S, Porat N. Persis tence of pathogens despite

clinical improvement in antibiotic-treated acute otitis media is associated with clinical and bacteriologic

relapse. Pediatr Infect Dis J. Apr 2008;27(4):296-301. [Medline].

35. Bakaletz LO. Immunopathogenesis of polymicrobial otitis media. J Leukoc Biol. Oct 20 2009;[Medline].

[Full Text].

36. Bauchner H, Marchant CD, Bisbee A, et al. Effectiveness of Centers for Disease Control and Prevention

recommendations for outcomes of acute otitis media. Pediatrics. Apr 2006;117(4):1009-17. [Medline].

37. Belshe RB, Gruber WC. Prevention of otit is media in children with live attenuated influenza vaccine given

intranasally. Pediatr Infect Dis J. May 2000;19(5 Suppl):S66-71. [Medline].

38. Bitar MA, Baz R, Sabra O. Who needs admiss ion among infants with acute otitis media?. J PaediatrChild Health. May 2012;48(5):435-8. [Medline].

39. Bitnun A, Allen UD. Medical therapy of otitis media: use, abuse, efficacy, and morbidity. J Otolaryngol.

1998;27 Suppl 2:26-36. [Medline].

40. Block SL. Management of acute otitis media in the 1990s: the decade of resistant pneumococcus.

Paediatr Drugs. Jan-Mar 1999;1(1):31-50. [Medline].

41. Bluestone CD. Clinical course, complications and sequelae of acute otitis media. Pediatr Infect Dis J.

May 2000;19(5 Suppl):S37-46. [Medline].

42. Blumer JL. Fundamental basis for rational therapeutics in acute otitis media. Pediatr Infect Dis J. Dec

1999;18(12):1130-40. [Medline].

43. Bradley JS. Oral vs. intramuscular antibiotic therapy for acute otitis media: which is best?. Pediatr Infect

Dis J. Dec 1999;18(12):1147-51. [Medline].

44. Brunton S, Pichichero ME. Acute otitis media: influence of the PCV-7 vaccine on changes in the disease

and its management. J Fam Pract. Nov 2005;54(11):961-8. [Medline].

45. Byington CL. The diagnosis and management of otitis media with effusion. Pediatr Ann. Feb

1998;27(2):96-100. [Medline].

46. Bylander-Groth A, Stenstrom C. Eustachian tube function and otitis media in children. Ear Nose Throat J.

Sep 1998;77(9):762-4, 766, 768-9. [Medline].

47. Cameron C, Dallaire F, Vzina C, Muckle G, Bruneau S, Ayotte P. Neonatal vitamin A deficiency and its

impact on acute respiratory infections among preschool Inuit children. Can J Public Health. Mar-Apr

2008;99(2):102-6. [Medline].

48. Canalis RF, Lambert PR. Acute suppurative otitis media and mastoiditis. In: Canalis RF, Lambert PR,

eds. The Ear: Comprehensive Otology. Lippincott; 2000:397-408.

49. Canalis RF, Lambert PR. Chronic otitis media and cholesteatoma. In: Canalis RF, Lambert PR, eds. The

Ear: Comprehensive Otology. Lippincott; 2000:409-31.

50. Carlson L, Scudder L. Controversies in the management of pediatric otitis media. Are more definitive

answers on the horizon?.Adv Nurse Pract. Feb 2004;12(2):73-7. [Medline].

51. Casey JR, Block S, Puthoor P, Hedrick J, Almudevar A, Pichichero ME. A simple scoring system to

improve clinical assessment of acute otitis media. Clin Pediatr (Phila). Jul 2011;50(7):623-9. [Medline].

52. Casselbrant ML, Mandel EM, Kurs-Lasky M, et al. Otitis media in a population of black American and
http://reference.medscape.com/medline/abstract/21471024http://reference.medscape.com/medline/abstract/14986495http://reference.medscape.com/medline/abstract/18457282http://reference.medscape.com/medline/abstract/9787519http://reference.medscape.com/medline/abstract/9523297http://reference.medscape.com/medline/abstract/16266602http://reference.medscape.com/medline/abstract/10608647http://reference.medscape.com/medline/abstract/10608645http://reference.medscape.com/medline/abstract/10821471http://reference.medscape.com/medline/abstract/10937477http://reference.medscape.com/medline/abstract/9800637http://reference.medscape.com/medline/abstract/22107109http://reference.medscape.com/medline/abstract/10821474http://reference.medscape.com/medline/abstract/16585294http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2812561/http://reference.medscape.com/medline/abstract/19843575http://reference.medscape.com/medline/abstract/18379372http://reference.medscape.com/medline/abstract/10688388http://reference.medscape.com/medline/abstract/15121966http://reference.medscape.com/medline/abstract/16634700


10/14



white American infants, 0-2 years of age. Int J Pediatr Otorhinolaryngol. Aug 1995;33(1):1-16. [Medline].

53. Chao JH, Kunkov S, Reyes LB, Lichten S, Crain EF. Comparison of two approaches to observation

therapy for acute otitis media in the emergency department. Pediatrics . May 2008;121(5):e1352-6.

[Medline].

54. Chartrand SA, Pong A. Acute otitis media in the 1990s: the impact of antibiotic resistance. Pediatr Ann.

Feb 1998;27(2):86-95. [Medline].

55. Chonmaitree T. Viral and bacterial interaction in acute otitis media. Pediatr Infect Dis J. May 2000;19(5

Suppl):S24-30. [Medline].

56. Chonmaitree T, Heikkinen T. Role of viruses in middle-ear disease. Ann N Y Acad Sci. Dec 29

1997;830:143-57. [Medline].

57. Christ ian-Kopp S, Sinha M, Rosenberg DI, Eisenhart AW, McDonald FW. Antibiotic dosing for acute otitis

media in children: a weighty issue. Pediatr Emerg Care. Jan 2010;26(1):19-25. [Medline].

58. Coco A, Vernacchio L, Horst M, Anderson A. Management of acute otitis media after publication of the

2004 AAP and AAFP clinical practice guideline. Pediatrics . Feb 2010;125(2):214-20. [Medline].

59. Conrad DA. Should acute otit is media ever be treated with antibiotics?. Pediatr Ann. Feb 1998;27(2):66-7,

70-4. [Medline].

60. Coulson CJ, Drake-Lee AB, Plant T, Drayson MT. Total serum IgE and IgE antibodies specific to house

dust mite found in two aged-matched cohorts of children with and without otitis media with effusion. Clin

Otolaryngol. Apr 2006;31(2):130-3. [Medline].

61. Dagan R, Leibovitch E, Fliss DM, Leiberman A. Treatment failures in otitis media--what can we learn?.

Ear Nose Throat J. Jun 1998;77(6 Suppl):16-9; discussion 20-1. [Medline].

62. Daly KA, Giebink GS. Clinical epidemiology of otitis media. Pediatr Infect Dis J. May 2000;19(5


63. Elsheikh MN, Mahfouz ME. Up-regulation of MUC5AC and MUC5B mucin genes in nasopharyngeal

respiratory mucosa and selective up-regulation of MUC5B in middle ear in pediatric otitis media witheffusion. Laryngoscope. Mar 2006;116(3):365-9. [Medline].

64. Eskola J, Kilpi T. Potential of bacterial vaccines in the prevention of acute otitis media. Pediatr Infect Dis

J. May 2000;19(5 Suppl):S72-8. [Medline].

65. Fergie JE, Purcell K. The role of inflammatory mediators and anti-inflammatory drugs in otitis media.

Pediatr Ann. Feb 1998;27(2):76-81. [Medline].

66. Finkelstein JA, Stille CJ, Rifas-Shiman SL, Goldmann D. Watchful waiting for acute otitis media: are

parents and physicians ready?. Pediatrics . Jun 2005;115(6):1466-73. [Medline]. [Full Text].

67. Gamboa S, Park MK, Wanserski G, Lo V. Clinical inquiries. Should you use antibiotics to treat acuteotitis media in children?. J Fam Pract. Nov 2009;58(11):602-4. [Medline].

68. Gauthier M, Chevalier I, Gouin S, Lamarre V, Abela A. Ceftriaxone for refractory acute otitis media:

impact of a clinical practice guideline. Pediatr Emerg Care. Nov 2009;25(11):739-43. [Medline].

69. Giebink GS. Vaccination against middle-ear bacterial and viral pathogens.Ann N Y Acad Sci. Dec 29

1997;830:330-52. [Medline].

70. Glasziou PP, Hayem M, Del Mar CB. Antibiotics for acute otitis media in children. Cochrane Database

Syst Rev. 2000;(2):CD000219. [Medline].

71. Gould JM, Matz PS. Otitis media. Pediatr Rev. Mar 2010;31(3):102-16. [Medline].

72. Gravel JS, Wallace IF. Language, speech, and educational outcomes of otitis media. J Otolaryngol.

1998;27 Suppl 2:17-25. [Medline].

73. Gven MG, Midilli K, Inci E, Kuskucu M, Tahamiler R, Ozergil E. Lack of Chlamydophila pneumoniae

and predominance of Alloiococcus otitidis in middle ear fluids of children with otitis media with effusion.
http://reference.medscape.com/medline/abstract/9800636http://reference.medscape.com/medline/abstract/20194902http://reference.medscape.com/medline/abstract/14973951http://reference.medscape.com/medline/abstract/9616694http://reference.medscape.com/medline/abstract/19864968http://reference.medscape.com/medline/abstract/19891939http://pediatrics.aappublications.org/content/115/6/1466.fullhttp://reference.medscape.com/medline/abstract/15930205http://reference.medscape.com/medline/abstract/9523295http://reference.medscape.com/medline/abstract/10821475http://reference.medscape.com/medline/abstract/16540890http://reference.medscape.com/medline/abstract/10821470http://reference.medscape.com/medline/abstract/9674330http://reference.medscape.com/medline/abstract/16620332http://reference.medscape.com/medline/abstract/9523294http://reference.medscape.com/medline/abstract/20100746http://reference.medscape.com/medline/abstract/20042912http://reference.medscape.com/medline/abstract/9616674http://reference.medscape.com/medline/abstract/10821469http://reference.medscape.com/medline/abstract/9523296http://reference.medscape.com/medline/abstract/18450878http://reference.medscape.com/medline/abstract/7558637


11/14



Auris Nasus Larynx. Oct 29 2009;[Medline].

74. Haddad MB, Porucznik CA, Joyce KE, De AK, Pavia AT, Rolfs RT. Risk factors for pediatric invasive

pneumococcal disease in the Intermountain West, 1996-2002.Ann Epidemiol. Feb 2008;18(2):139-46.

[Medline].

75. Handler SD, Magardino TM. Otitis media with effusion. In: Canalis RF, Lambert PR, eds. The Ear:

Comprehensive Otology. Lippincott; 2000:383-96.

76. Hashisaki GT. Complications of chronic otitis media. In: Canalis RF, Lambert PR, eds. The Ear:

Comprehensive Otology. Lippincott; 2000:433-45.

77. Heikkinen T. Role of viruses in the pathogenesis of acute otit is media. Pediatr Infect Dis J. May

2000;19(5 Suppl):S17-22; discussion S22-3. [Medline].

78. Heikkinen T, Chonmaitree T. Increasing importance of viruses in acute otit is media.Ann Med. Apr

2000;32(3):157-63. [Medline].

79. Hoberman A, Paradise JL, Cohen R. Duration of therapy for acute otitis media. Pediatr Infect Dis J. May

2000;19(5):471-3. [Medline].

80. Jacobs MR. Antibiotic -resistant Streptococcus pneumoniae in acute otitis media: overview and update.

Pediatr Infect Dis J. Oct 1998;17(10):947-52. [Medline].

81. Jacobs MR. Increasing antibiotic resistance among otitis media pathogens and their susceptibility to oral

agents based on pharmacodynamic parameters. Pediatr Infect Dis J. May 2000;19(5 Suppl):S47-55;

discussion S55-6. [Medline].

82. Jones LL, Hassanien A, Cook DG, Britton J, Leonardi-Bee J. Parental smoking and the risk of middle ear

disease in children: a systematic review and meta-analysis. Arch Pediatr Adolesc Med. Jan

2012;166(1):18-27. [Medline].

83. Jung TT, Hanson JB. Classification of otitis media and surgical principles. Otolaryngol Clin North Am. Jun

1999;32(3):369-83. [Medline].

84. Kaleida PH, Fireman P. Diagnostic assessment of otitis media. Clin Allergy Immunol. 2000;15:247-62.[Medline].

85. Kaleida PH, Ploof DL, Kurs-Lasky M, Shaikh N, Colborn DK, Haralam MA. Mastering diagnostic skills:

Enhancing Proficiency in Otitis Media, a model for diagnostic skills training. Pediatrics. Oct

2009;124(4):e714-20. [Medline].

86. Kenna MA. Diagnosis and management of otitis media with effusion. In: Cotton RT, Myer CM III, eds.

Practical Pediatric Otolaryngology. Lippincott;1999:229-46.

87. Kenna MA. Otitis media with effusion. In: Bailey BJ, Calhoun KH eds. Head and Neck Surgery:

Otolaryngology. 2nd ed. Lippincott-Raven Pub; 1998:1297-310.

88. Klein J, Chan S. Methici llin-resistant Staphylococcus aureus in middle ear fluid of children. Clin Pediatr

(Phila). Jan 2010;49(1):66-8. [Medline].

89. Klein JO. Nonimmune strategies for prevention of otit is media. Pediatr Infect Dis J. May 2000;19(5


90. Kong K, Coates HL. Natural history, definitions, risk factors and burden of otitis media. Med J Aust. Nov 2

2009;191(9):S39-43. [Medline].

91. Kozyrskyj AL, Hildes-Ripstein GE, Longstaffe SE, et al. Short course antibiotics for acute otitis media.

Cochrane Database Syst Rev. 2000;(2):CD001095. [Medline].

92. Laine MK, Thtinen PA, Ruuskanen O, Huovinen P, Ruohola A. Symptoms or symptom-based scorescannot predict acute otitis media at otitis-prone age. Pediatrics. May 2010;125(5):e1154-61. [Medline].

93. Lannon C, Peterson LE, Goudie A. Quality measures for the care of children with otitis media with

effusion. Pediatrics . Jun 2011;127(6):e1490-7. [Medline].
http://reference.medscape.com/medline/abstract/21606146http://reference.medscape.com/medline/abstract/20368317http://reference.medscape.com/medline/abstract/10796591http://reference.medscape.com/medline/abstract/19883355http://reference.medscape.com/medline/abstract/10821477http://reference.medscape.com/medline/abstract/19628757http://reference.medscape.com/medline/abstract/19786431http://reference.medscape.com/medline/abstract/10943297http://reference.medscape.com/medline/abstract/10393773http://reference.medscape.com/medline/abstract/21893640http://reference.medscape.com/medline/abstract/10821472http://reference.medscape.com/medline/abstract/9802651http://reference.medscape.com/medline/abstract/10819346http://reference.medscape.com/medline/abstract/10821322http://reference.medscape.com/medline/abstract/11163463http://reference.medscape.com/medline/abstract/18191761http://reference.medscape.com/medline/abstract/19879704


12/14



94. Laurens MB, Becker RM, Johnson JK, Wolf JS, Kotloff KL. MRSA with progression from otitis media and

sphenoid sinusitis to clival osteomyelitis, pachymeningitis and abducens nerve palsy in an

immunocompetent 10-year-old patient. Int J Pediatr Otorhinolaryngol. May 8 2008;[Medline].

95. Leibovitz E. Acute otitis media in pediatric medicine: current issues in epidemiology, diagnosis, and

management. Paediatr Drugs. 2003;5 Suppl 1:1-12. [Medline].

96. Leibovitz E, Broides A, Greenberg D, Newman N. Current management of pediatric acute otit is media.

Expert Rev Anti Infect Ther. Feb 2010;8(2):151-61. [Medline].

97. Lim DJ. Recent advances in otit is media. Report of the sixth research conference.Ann Otol Rhinol

Laryngol Suppl. Oct 1998;174:1-94.

98. Lin HW, Shargorodsky J, Gopen Q. Clinical strategies for the management of acute mastoidit is in the

pediatric population. Clin Pediatr (Phila). Feb 2010;49(2):110-5. [Medline].

99. Lin YS, Lee FP, Peng SC. Complications in children with long-term cochlear implants. ORL J

Otorhinolaryngol Relat Spec. 2006;68(4):237-42. [Medline].

100. Marchant CD. Managing acute otitis media: current clinical st rategies. In: Physician's Desk Reference

2000. Medical Economics; 2000:101-15.

101. Marchetti F, Bua J, Ventura A. Pneumococcal vaccination for acute otitis media. Lancet. Jun 102006;367(9526):1897; author reply 1898. [Medline].

102. Massa HM, Cripps AW, Lehmann D. Otitis media: viruses, bacteria, biofilms and vaccines. Med J Aust.

Nov 2 2009;191(9):S44-9. [Medline].

103. [Best Evidence] McCormick DP, Chonmaitree T, Pittman C, et al. Nonsevere acute otitis media: a clinical

trial comparing outcomes of watchful waiting versus immediate antibiotic treatment. Pediatrics . Jun

2005;115(6):1455-65. [Medline]. [Full Text].

104. McCracken GH Jr. Prescribing antimicrobial agents for treatment of acute otit is media. Pediatr Infect Dis

J. Dec 1999;18(12):1141-6. [Medline].

105. Meisel SR, Shimon I, Edgington TS, et al. Leukaemia inhibitory factor enhances t issue factor expressionin human monocyte-derived macrophages: a gp130-mediated mechanism. Br J Haematol. Dec

1999;107(4):747-55. [Medline].

106. Meropol SB. Valuing reduced antibiotic use for pediatric acute otitis media. Pediatrics. Apr

2008;121(4):669-73. [Medline].

107. Meropol SB, Glick HA, Asch DA. Age inconsistency in the American Academy of Pediatrics guidelines

for acute otitis media. Pediatrics. Apr 2008;121(4):657-68. [Medline].

108. Morris PS, Leach AJ. Acute and chronic otitis media. Pediatr Clin North Am. Dec 2009;56(6):1383-99.

[Medline].

109. Murphy TF. Bacterial otitis media: pathogenetic considerations. Pediatr Infect Dis J. May 2000;19(5

Suppl):S9-15; discussion S15-6. [Medline].

110. Oomen KP, Rovers MM, van den Akker EH, et al. Effect of adenotonsillectomy on middle ear status in

children. Laryngoscope. Apr 2005;115(4):731-4. [Medline].

111. Paradise JL. Otitis media and child development: should we worry?. Pediatr Infect Dis J. Nov

1998;17(11):1076-83; discussion 1099-100. [Medline].

112. Paradise JL, Hoberman A, Rockette HE, Shaikh N. Treating Acute Otitis Media in Young Children: What

Constitutes Success?. Pediatr Infect Dis J. Feb 21 2013;[Medline].

113. Pichichero M. Widening differences in acute otitis media study populations. Clin Infect Dis. Dec 12009;49(11):1648-9. [Medline].

114. Pichichero M. Widening differences in acute otitis media study populations. Clin Infect Dis. Dec 1

2009;49(11):1648-9. [Medline].
http://reference.medscape.com/medline/abstract/19886802http://reference.medscape.com/medline/abstract/19886802http://reference.medscape.com/medline/abstract/23435311http://reference.medscape.com/medline/abstract/9850002http://reference.medscape.com/medline/abstract/15805889http://reference.medscape.com/medline/abstract/10821467http://reference.medscape.com/medline/abstract/19962027http://reference.medscape.com/medline/abstract/18381528http://reference.medscape.com/medline/abstract/18381529http://reference.medscape.com/medline/abstract/10606879http://reference.medscape.com/medline/abstract/10608646http://pediatrics.aappublications.org/content/115/6/1455.fullhttp://reference.medscape.com/medline/abstract/15930204http://reference.medscape.com/medline/abstract/19883356http://reference.medscape.com/medline/abstract/16765748http://reference.medscape.com/medline/abstract/16567948http://reference.medscape.com/medline/abstract/19734439http://reference.medscape.com/medline/abstract/20109045http://reference.medscape.com/medline/abstract/14632101http://reference.medscape.com/medline/abstract/18472169


13/14



115. Pichichero ME. Acute otitis media: Part I. Improving diagnostic accuracy.Am Fam Physician. Apr 1

2000;61(7):2051-6. [Medline].

116. Pichichero ME. Acute otit is media: part II. Treatment in an era of increasing antibiotic resistance.Am

Fam Physician. Apr 15 2000;61(8):2410-6. [Medline].

117. Pollock TJ, Kim P, Sargent MA, Aroichane M, Lyons CJ, Gardiner JA. Ophthalmic complications of otitis

media in children. J AAPOS. Jun 2011;15(3):272-5. [Medline].

118. Poole MD. Implications of drug-resistant Streptococcus pneumoniae for otitis media. Pediatr Infect Dis J.

Oct 1998;17(10):953-6. [Medline].

119. Porat N, Amit U, Givon-Lavi N, Leibovitz E, Dagan R. Increasing Importance of Multidrug-Resistant

Serotype 6A Streptococcus pneumoniae Clones in Acute Otitis Media in Southern Israel. Pediatr Infect

Dis J. Nov 18 2009;[Medline].

120. Pransky SM. Surgical strategies for otitis media. J Otolaryngol. 1998;27 Suppl 2:37-42. [Medline].

121. Ramilo O. Role of respiratory viruses in acute otitis media: implications for management. Pediatr Infect

Dis J. Dec 1999;18(12):1125-9. [Medline].

122. Rawof S, Upadhye S. Antibiotics for acute otit is media: Which children are likely to benefit?. CJEM. Nov

2009;11(6):553-557. [Medline].

123. Raza M, Jalil J, Shafique M, Ghafoor T. Frequency of otit is media with effusion in recurrent upper

respiratory tract infection in children. J Coll Physicians Surg Pak. Apr 2008;18(4):226-9. [Medline].

124. Rosenblut A, Santolaya ME, Gonzalez P, et al. Penicillin resistance is not extrapolable to amoxicillin

resistance in Streptococcus pneumoniae isolated from middle ear fluid in children with acute otitis media.

Ann Otol Rhinol Laryngol. Mar 2006;115(3):186-90. [Medline].

125. Rubin LG, Papsin B. Cochlear implants in children: surgical site infections and prevention and treatment

of acute otitis media and meningitis. Pediatrics . Aug 2010;126(2):381-91. [Medline].

126. Shaikh N, Hoberman A. Update: acute otitis media. Pediatr Ann. Jan 2010;39(1):28-33. [Medline].

127. Shaikh N, Hoberman A, Kaleida PH, Rockette HE, Kurs-Lasky M, Hoover H, et al. Otoscopic signs of

otitis media. Pediatr Infect Dis J. Oct 2011;30(10):822-6. [Medline].

128. Shaikh N, Hoberman A, Kurs-Lasky M, Rockette HE, Chandra A, Colborn DK, et al. Pain management in

young children undergoing diagnostic tympanocentesis. Clin Pediatr (Phila). Mar 2011;50(3):231-6.

[Medline].

129. Shaikh N, Hoberman A, Rockette HE, Kurs-Lasky M. Development of an algorithm for the diagnosis of

otitis media.Acad Pediatr. May 2012;12(3):214-8. [Medline].

130. Shihada R, Lurie M, Luntz M. Skull base meningiomas mimicking otitis media. J Laryngol Otol. Jun

2012;126(6):619-24. [Medline].

131. Sibbald AD. Acute otitis media in infants: the disease and the illness. Clinical distinctions for the new

treatment paradigm. Otolaryngol Head Neck Surg. Oct 2012;147(4):606-10. [Medline].

132. Siegel RM. Acute otit is media guidelines, antibiotic use, and shared medical decision-making. Pediatrics .

Feb 2010;125(2):384-6. [Medline].

133. Silveira Netto LF, da Costa SS, Sleifer P, Braga ME. The impact of chronic suppurative otitis media on

children's and teenagers' hearing. Int J Pediatr Otorhinolaryngol. Oct 22 2009;[Medline].

134. Sixth Research Conference. Recent advances in otitis media. Report of the sixth research conference.

Ann Otol Rhinol Laryngol Suppl. Oct 1998;174:1-94. [Medline].

135. Steinmann K, Babl FE. Antibiotic prescribing rates for acute otitis media in a paediatric emergency

department. J Paediatr Child Health. Apr 2006;42(4):204-5. [Medline].

136. Syggelou A, Fanos V, Iacovidou N. Acute otitis media in neonatal life: a review. J Chemother. Jun

2011;23(3):123-6. [Medline].
http://reference.medscape.com/medline/abstract/21742578http://reference.medscape.com/medline/abstract/16630322http://reference.medscape.com/medline/abstract/9798459http://reference.medscape.com/medline/abstract/19853931http://reference.medscape.com/medline/abstract/20100752http://reference.medscape.com/medline/abstract/22864406http://reference.medscape.com/medline/abstract/22494527http://reference.medscape.com/medline/abstract/22459064http://reference.medscape.com/medline/abstract/21098520http://reference.medscape.com/medline/abstract/21844828http://reference.medscape.com/medline/abstract/20151622http://reference.medscape.com/medline/abstract/20660544http://reference.medscape.com/medline/abstract/16572607http://reference.medscape.com/medline/abstract/18474156http://reference.medscape.com/medline/abstract/19922716http://reference.medscape.com/medline/abstract/10608644http://reference.medscape.com/medline/abstract/9800638http://reference.medscape.com/medline/abstract/19927039http://reference.medscape.com/medline/abstract/9802652http://reference.medscape.com/medline/abstract/21777800http://reference.medscape.com/medline/abstract/10794582http://reference.medscape.com/medline/abstract/10779248


14/14


Medscape Reference 2011 WebMD, LLC

137. Tarlow M. Otitis media: pathogenesis and medical sequelae. Ear Nose Throat J. Jun 1998;77(6 Suppl):3-

6. [Medline].

138. Thompson PL, Gilbert RE, Long PF, Saxena S, Sharland M, Wong IC. Effect of antibiotics for otitis media

on mastoiditis in children: a retrospective cohort study using the United kingdom general practice

research database. Pediatrics . Feb 2009;123(2):424-30. [Medline].

139. Wanna GB, Dharamsi LM, Moss JR, Bennett ML, Thompson RC, Haynes DS. Contemporary

Management of Intracranial Complications of Otit is Media. Otol Neurotol. Oct 31 2009;[Medline].

140. Williams CJ, Jacobs AM. The impact of otitis media on cognitive and educational outcomes. Med J Aust.

Nov 2 2009;191(9):S69-72. [Medline].

141. Yilmaz T, Ceylan M, Akyon Y, et al. Helicobacter pylori: a possible association with otitis media with

effusion. Otolaryngol Head Neck Surg. May 2006;134(5):772-7. [Medline].
http://reference.medscape.com/medline/abstract/16647533http://reference.medscape.com/medline/abstract/19883361http://reference.medscape.com/medline/abstract/19887978http://reference.medscape.com/medline/abstract/19171605http://reference.medscape.com/medline/abstract/9674327

otitis media clinical presentation

Documents