INTRODUCTION

The last three decades have seen an expansion in the number of children treated with antibiotics for acute otitis media (AOM) both as a result of the failure to differentiate AOM from otitis media with effusion (OME) and true increases in the frequency of disease most likely associated with the changing nature of day-care attendance. This increased use of antibiotics has, in part, provided the selective pressure to promote the emergence of resistance among the three major otopathogens, Streptococcus pneumoniae, nontypable Haemophilus influenzae, and Moraxella cattharalis. Although briefly halted in association with the introduction of pneumococcal conjugate vaccine, resistance has once again begun to increase among isolates of Streptococcus pneumoniae with multidrug-resistant serotype 19A emerging as a significant cause of treatment failure. These events warrant a re-evaluation of the diagnosis and treatment of AOM, with an emphasis on distinguishing acute disease from OME and selection of antimicrobial therapy that results in sterilization of the middle ear fluid.

DIAGNOSIS

The American Academy of Pediatrics (AAP) guidelines, published in 2003, codify principles for improving the diagnosis of AOM. Criteria that distinguish AOM from OME were established (Figure 6.1) to promote the judicious use of antimicrobial therapy in otitis media. The AAP guidelines require the presence of middle ear effusion as detected by physical exam or tympanometry as a critical criterion. In addition to middle ear fluid, the diagnosis requires new onset of signs and symptoms such as earache, ear tugging, or a bulging tympanic membrane.