Tools
Acute Otitis Media
Introduction
Otitis media is a spectrum of middle ear conditions that includes acute otitis media (AOM), recurrent AOM, otitis media with effusion, and chronic suppurative otitis media (CSOM). The main symptom of AOM is middle ear effusion, accompanied by signs of acute illness, such as ear pain; otorrhea (ie, fluid drainage from the ear); ear tugging; fever; irritability; anorexia; vomiting; or diarrhea.[1] AOM is the second most common pediatric diagnosis in the emergency department, after upper respiratory infections. Although otitis media can occur at any age, the condition is most commonly observed between 6 and 24 months.[2] A diagnosis of AOM is the most common reason for antibiotic use in childhood, although most cases of AOM resolve spontaneously.[3] Advances in antibiotic treatment strategies, the widespread adoption of preventive measures, and greater adherence to scientific society guidelines have contributed to a decline in AOM incidence.[4]
AOM is a bacterial or viral infection of the middle ear that may extend to surrounding structures. The most common bacterial pathogens that cause AOM include Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis. Following the introduction of conjugate pneumococcal vaccines, pneumococcal organisms have shifted to non-vaccine serotypes. The most common viral pathogens of AOM include respiratory syncytial virus (RSV), coronaviruses, influenza viruses, adenoviruses, human metapneumovirus, and picornaviruses.[5][6][7] Although AOM is primarily bacterial, viral upper respiratory infections, including SARS-CoV-2, commonly precede it, a relationship reflected in the reduced AOM incidence during periods of widespread viral mitigation measures, such as during the COVID-19 pandemic.[8][9][10]
Otitis media is diagnosed clinically based on physical exam findings (pneumatic otoscopy), along with the patient's history and presenting signs and symptoms. Diagnostic challenges in accurately identifying AOM include interobserver reliability and bias, patient cooperation, and narrow ear canals in children.[11][12] Several tools are available to aid in diagnosing otitis media, including tympanometry, acoustic reflectometry, audiometry (pure-tone and play), and acoustic reflexes. Pneumatic otoscopy is the most reliable method for assessing the tympanic membrane; the method has higher sensitivity and specificity than plain otoscopy, though tympanometry and artificial intelligence can facilitate diagnosis if pneumatic otoscopy is unavailable.[13][14] Newer tools have become available, including video-otoscopy, which enables the collection of a large number of tympanic membrane images. Unlike standard otoscopy, these images can be reviewed later by the diagnosing clinician or a specialist, thus enabling a more detailed analysis of the tympanic membrane and reducing the risk of misdiagnosis.[15] Another development in otoscopy is telemedical otoscopic examination, in which parents use smartphone-based otoscopes to capture images suggestive of ear disease and transmit them to a primary care pediatrician or an otolaryngologist for confirmation. With appropriate parental education in device use, telemedical otoscopic examination could be integrated into routine clinical practice.[13][16]
Management of AOM varies by clinical setting and reflects differences in guideline interpretation and risk tolerance. In the United States, the mainstay of treatment for an established diagnosis is high-dose amoxicillin, particularly in children younger than 2. In contrast, some countries, such as the Netherlands, recommend an initial period of watchful waiting with antibiotics reserved for persistent or worsening symptoms.[17] These approaches balance concerns about antibiotic overuse and resistance with the benefits of early treatment in higher-risk patients. If inadequately treated, AOM may lead to complications including hearing loss, balance disturbances, tympanic membrane perforation, cholesteatoma, and, rarely, mastoiditis, labyrinthitis, petrositis, meningitis, brain abscess, and lateral or cavernous sinus thrombosis.[18] Regardless of antibiotic strategy, analgesics such as nonsteroidal anti-inflammatory drugs or topical 1% lidocaine should be used alone or in combination to achieve effective pain control.[19]
Surgical management of AOM may be diagnostic, therapeutic, or preventive. Tympanocentesis is generally reserved for patients who are immunocompromised, have severe complications (eg, meningitis), or have infections unresponsive to antimicrobial therapy. Myringotomy with tympanostomy tube placement may be indicated for recurrent AOM or acute exacerbations of CSOM. In rare cases, mastoidectomy is required for infection spread or other complications, although its use has declined with earlier diagnosis and effective medical therapy. Historically, surgical drainage of ear infections predates modern antibiotic management, with mastoidectomy described before myringotomy and early procedures reported as far back as the 16th century.[20]
Etiology
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Etiology
AOM is a multifactorial condition arising from the interaction of infectious pathogens, host susceptibility, and environmental exposures.[21][22] Disruption of Eustachian tube function, often following a viral upper respiratory infection, facilitates middle ear inflammation and microbial proliferation. Both modifiable and nonmodifiable factors contribute to disease risk. The causes and risk factors for AOM include, but are not limited to, the following:
- Immunocompromise (eg, HIV, diabetes mellitus, and primary immunodeficiencies)
- Genetic predisposition
- Craniofacial or palatal abnormalities impairing Eustachian tube function (eg, cleft palate and tensor veli palatini dysfunction)
- Ciliary dysfunction (eg, primary ciliary dyskinesia)
- Cochlear implants
- Vitamin A deficiency
- Bacterial pathogens (eg, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis)
- Viral pathogens (eg, RSV, influenza virus, parainfluenza virus, rhinovirus, and adenovirus)
- Allergies
- Absence or shorter duration of breastfeeding
- Environmental exposures (eg, passive smoke exposure and daycare attendance)
- Lower socioeconomic status
- Family history of recurrent AOM (parents or siblings) [23][24][25]
Epidemiology
Otitis media is a global concern, though the exact number of cases per year is difficult to determine due to limited reporting and varying incidence rates across regions. The peak incidence of AOM occurs between 6 and 12 months of age and declines after 5 years of age due to changes in the angle of the Eustachian tube. Approximately 80% of children experience AOM during their lifetime, and between 80% and 90% experience otitis media with effusion before school age. The condition demonstrates a slight male preponderance and is more common in children than in adults; however, rates are higher in adults with a history of recurrent AOM in childhood, cleft palate, primary immunodeficiency, or immunocompromised status.[26][27] The most important sociodemographic risk factors for AOM appear to be low socioeconomic status and repeated exposure to large numbers of other children, whether at home or in day care.[28]
Pathophysiology
Most cases of AOM begin with inflammation following a viral upper respiratory infection. The inflammation affects the nasal mucosa, nasopharynx, middle ear lining, and Eustachian tubes. Because the middle ear has limited space, inflammation-related swelling obstructs the narrow Eustachian tube, thereby reducing ventilation, an early and critical step in disease development. Obstruction of the Eustachian tube triggers a cascade of events, including increased negative pressure in the middle ear, increased exudate from the inflamed mucosa, and a buildup of mucosal secretions. The stasis of secretions allows bacterial and viral organisms to colonize the middle ear. The growth of these microbes in the middle ear leads to suppuration and, eventually, frank purulence, clinically demonstrated by a bulging or erythematous tympanic membrane and purulent middle ear fluid (see Image. Acute Otitis Media Pathophysiology). AOM must be differentiated from CSOM, which presents with thick, amber-colored fluid in the middle ear and a retracted tympanic membrane on otoscopic examination. Both conditions show decreased tympanic membrane mobility on tympanometry or pneumatic otoscopy, along with hearing loss, leading to misdiagnosis and improper management.
Several risk factors can predispose children to AOM. A preceding upper respiratory tract infection is the most common risk factor. Other risk factors include male sex, adenoid hypertrophy (obstructive), allergy, daycare attendance, environmental smoke exposure, pacifier use, immunodeficiency, gastroesophageal reflux, parental history of recurrent childhood AOM, and other genetic predispositions.[29][30][31]
Histopathology
In clinical practice, histologic biopsy is not performed for AOM outside research settings; however, histopathologic findings described in experimental and surgical specimens provide insight into the underlying disease process. These observations demonstrate that otitis media involves inflammation of the middle ear that progresses from acute to subacute stages and, in some cases, to a chronic phase associated with irreversible tissue damage.[32]
During the acute stage, changes occur primarily within the lamina propria of the middle ear mucosa. The inflammatory response is characterized by capillary dilation and increased vascular permeability, leading to edema of the lamina propria and leukocyte infiltration. The cellular infiltrate consists predominantly of polymorphonuclear leukocytes, which may contribute to purulence. The associated serous fluid is likely a blood-serum derivative.
In the subacute stage, mucosal metaplasia becomes evident, characterized by a marked increase in ciliated and secretory epithelial cells.[33] Epithelial remodeling progresses with an expansion of goblet cells and enhanced mucous production, contributing to persistent middle ear effusion. Continued inflammatory signaling promotes these structural changes and may impair mucociliary clearance, facilitating ongoing fluid retention and delayed resolution.
Chronic otitis media is characterized by permanent structural alterations of the middle ear.[34][35] Histopathologic findings include an increased number of mononuclear cells and granulation tissue proliferation, a highly vascular connective tissue that may contribute to persistent inflammation and bone resorption. Advanced changes may include the development of cholesteatoma, cholesterol cysts, granuloma, and tympanosclerosis.
History and Physical
Otalgia, or ear pain, is one of the most reliable indicators of otitis media; however, many children with AOM show nonspecific signs and symptoms, which can complicate diagnosis. Common symptoms include pulling or tugging at the ears, irritability, headaches, disturbed or restless sleep, poor feeding, loss of appetite, vomiting, or diarrhea. Approximately two-thirds of affected patients also present with fever, typically low-grade.
The diagnosis of otitis media primarily relies on the patient's history and clinical findings, with the aforementioned symptoms providing additional support. Diagnosis does not require laboratory tests or imaging studies. According to guidelines from the American Academy of Pediatrics (AAP), a diagnosis of AOM requires evidence of either moderate-to-severe tympanic membrane bulging or new-onset ear discharge (otorrhea) not related to otitis externa. Alternatively, mild tympanic membrane bulging can indicate AOM if accompanied by recent ear pain or erythema. These criteria are designed to assist primary care clinicians in making accurate diagnoses and informed clinical decisions but are not meant to replace clinical judgment.[36]
The otoscopic (pneumatic) examination is the first and most effective method for examining the ear, as it provides an immediate diagnosis for the experienced clinician (see Image. Acute Otitis Media on Otoscopy). In AOM, the tympanic membrane may appear erythematous or normal, and fluid in the middle ear space may be present, with decreased mobility on insufflation. In cases of suppurative otitis media, purulent fluid is clearly visible, and the tympanic membrane may appear bulging.
The external auditory canal may also be somewhat edematous; however, significant edema should raise suspicion for otitis externa, which may impact management. Otitis externa may occur simultaneously with AOM and may necessitate both topical and systemic treatment. If the tympanic membrane is perforated, the edema of the external auditory canal can be considered reactive.[37][38] Clinicians should also examine the mastoid region posterior to the ear for overlying edema, erythema, or tenderness that is disproportionate to the examination, as these features may raise concern for mastoiditis.[39] If the patient can follow complex instructions, a tuning fork exam can be performed to complement otoscopic findings. Using a 512-Hz tuning fork, the Rinne test can be performed to compare the quality of air versus bone conduction; in AOM, bone conduction is louder than air conduction. The Weber test can be performed by placing the tuning fork at the center of the forehead or on the teeth; in cases of AOM with conductive hearing loss, the sound lateralizes to the affected side.
Evaluation
Evaluation of AOM begins with a focused clinical assessment, including history and physical examination, with particular emphasis on otoscopic findings.[40][41] Pneumatic otoscopy remains the primary diagnostic tool, as it allows assessment of tympanic membrane mobility and the presence of middle ear effusion. Accurate diagnosis relies on correlating these findings with clinical symptoms, given the overlap with other middle ear conditions. Additional diagnostic modalities may support evaluation in selected cases but do not replace careful otoscopic examination.
Laboratory evaluation is not routinely required in the assessment of AOM. Clinicians may consider a comprehensive sepsis workup in infants younger than 12 weeks who present with fever without an identifiable source, although AOM alone does not typically warrant this evaluation. Targeted laboratory testing may help identify associated systemic or congenital conditions when clinically suspected. Culture and sensitivity testing of otorrhea, particularly from a fresh perforation or tympanocentesis specimen, may help guide antibiotic selection. Emerging diagnostic approaches include rapid serum biomarker analysis, with studies investigating proteins such as S100A12 and interleukin-10 to identify AOM caused by NHTi.[42]
Imaging studies do not play a routine role in the evaluation of uncomplicated AOM and are reserved for cases with suspected complications.[43][44] Computed tomography of the temporal bones may identify intratemporal and intracranial complications, including mastoiditis, epidural abscess, sigmoid sinus thrombophlebitis, meningitis, brain abscess, subdural abscess, ossicular involvement, and cholesteatoma. Magnetic resonance imaging provides additional sensitivity for intracranial pathology and may further characterize suspected complications.
Tympanocentesis may be performed to confirm the presence of middle ear effusion and obtain fluid for microbiologic analysis. This procedure improves diagnostic accuracy and allows targeted antimicrobial therapy based on culture results. Clinical practice reserves tympanocentesis for select situations, including neonatal patients, individuals with immunocompromising conditions, and cases of antibiotic treatment failure or severe disease.[45][46]
Audiologic evaluation plays a supportive role in selected patients with AOM. Conductive hearing loss commonly accompanies middle ear effusion, which may limit the ability to distinguish AOM from CSOM solely on the basis of hearing assessment. Tympanometry and acoustic reflectometry may demonstrate middle ear fluid but do not reliably differentiate between these conditions.[47] Audiometric testing may benefit patients with recurrent AOM, persistent effusion, CSOM, or suspected complications. Available modalities include play audiometry, pure-tone audiometry, otoacoustic emissions, speech reception threshold testing, and acoustic reflex testing.
Treatment / Management
Once the diagnosis of AOM is established, the goal of treatment is to control pain and treat the infectious process with antibiotics. Nonsteroidal anti-inflammatory drugs, acetaminophen, or even topical 1% lidocaine can be used to achieve pain control. The use of antibiotics for early otitis media is debated globally, and guidelines may vary by country. Although not widely accepted in the United States, watchful waiting is practiced in most European countries, with an emphasis on strong stewardship culture, family and clinician rapport, and the desire of parents to participate in decision-making.[48] However, in cases with clinical evidence of suppurative AOM, oral antibiotics are universally indicated, and high-dose amoxicillin or a second-generation cephalosporin is first-line therapy. In cases with tympanic membrane perforation, treatment should proceed with ototopical antibiotics safe for middle ear use (eg, ofloxacin) rather than systemic antibiotics, as topical agents deliver much higher concentrations of antibiotics without systemic adverse effects.[40]
When a bacterial etiology is suspected, the antibiotic of choice is high-dose amoxicillin orally for 10 days in both children and adult patients who are not allergic to penicillin. Amoxicillin has good efficacy in the treatment of AOM due to its high concentration in the middle ear. In cases of penicillin allergy, the AAP recommends either a single dose of azithromycin (10 mg/kg) or clarithromycin (15 mg/kg/d in 2 divided doses). Other options for patients allergic to penicillin are cefdinir (14 mg/kg/d in 1 or 2 doses), cefpodoxime (10 mg/kg/d, once daily), or cefuroxime (30 mg/kg/d in 2 divided doses).
For patients whose symptoms do not improve after treatment with high-dose amoxicillin, high-dose amoxicillin-clavulanate (90 mg/kg/d of amoxicillin component, with 6.4 mg/kg/d of clavulanate in 2 divided doses) should be given. In children for whom oral antibiotics cannot be administered (eg, vomiting), ceftriaxone (50 mg/kg/d) for 3 consecutive days, either intravenously or intramuscularly, is an alternative. Systemic steroids and antihistamines have not been shown to have any significant benefits.[36][49][50][51][52][53](A1)
Patients who have experienced 3 episodes of AOM in 6 months, or 4 or more episodes in 12 months, should be considered candidates for myringotomy with tube placement (tympanostomy), according to AAP guidelines. Recurrent infections requiring antibiotics are clinical evidence of Eustachian tube dysfunction, and placement of a tympanostomy tube allows ventilation of the middle ear space, restores normal hearing, and prevents speech delay. Furthermore, patients with functioning tympanostomy tubes who acquire AOM can be treated with ototopical antibiotic drops rather than systemic antibiotics.[54]
| Pause and Reflect |
A 5-year-old girl presents with her parent to the pediatrician's office. She has been experiencing rhinorrhea and cough, and she has been increasingly fussy over the past 4 days. The parent also reports tugging on the left ear.
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Differential Diagnosis
The differential diagnosis of AOM includes a range of infectious, inflammatory, and structural conditions that may present with overlapping symptoms such as ear pain, fever, irritability, or hearing changes. Careful clinical evaluation, particularly otoscopy, remains essential to distinguish AOM from other causes of middle ear effusion or otalgia, as well as from systemic illnesses that may present with nonspecific symptoms in infants and young children. Consideration of patient age, symptom pattern, and associated findings helps guide appropriate diagnosis and management.[55][56][57] The following conditions are considered in the differential diagnosis of AOM.
- Cholesteatoma
- Fever in the infant and toddler
- Fever without a source
- Hearing impairment
- Pediatric nasal polyps
- Nasopharyngeal cancer
- Otitis externa
- Human parainfluenza virus and other parainfluenza viruses
- Passive smoking and lung disease
- Pediatric allergic rhinitis
- Pediatric bacterial meningitis
- Pediatric gastroesophageal reflux
- Pediatric Haemophilus influenzae infection
- Pediatric HIV infection
- Pediatric mastoiditis
- Pediatric pneumococcal infections
- Primary ciliary dyskinesia
- RSV infection
- Rhinovirus infection (common cold)
- Teething
Prognosis
The prognosis for most patients with otitis media is excellent.[58] In modern times, mortality from AOM is uncommon. Improved healthcare access in developed nations allows for early diagnosis and treatment, leading to better outcomes. Several prognostic factors influence disease progression. Children with fewer than 3 episodes of AOM are approximately 3 times more likely to recover with a single antibiotic course; infections occurring outside the winter season are also associated with improved treatment responses.[59]
Pediatric cases of complicated AOM can be challenging to treat and are associated with high recurrence rates. These cases often require prolonged therapy, close follow-up, and, in some instances, surgical intervention. Although intratemporal and intracranial complications are very rare, they carry significant morbidity and mortality risks.[60]
Children who experience prelingual otitis media are at risk of developing mild-to-moderate conductive hearing loss. Recurrent or persistent middle ear effusion during this critical developmental period may impair auditory input. Reduced perception of high-frequency consonants, particularly sibilants, can affect speech and language development during the first 24 months of life.
Complications
The treatment of complications arising from middle ear conditions is particularly challenging due to the complex anatomy involved. These complications can be categorized into 2 main types: intratemporal, which occur within the temporal bone, and intracranial, which extend into the cranial cavity.[60][61][62]
- Intratemporal complications
- Hearing loss (conductive and sensorineural)
- Tympanic membrane perforation (acute and chronic)
- CSOM (with or without cholesteatoma)
- Cholesteatoma
- Tympanosclerosis
- Mastoiditis
- Petrositis
- Labyrinthitis
- Facial paralysis
- Cholesterol granuloma
- Infectious eczematoid dermatitis
- Intracranial complications
- Meningitis
- Subdural empyema
- Brain abscess
- Extradural abscess
- Lateral sinus thrombosis
- Otitic hydrocephalus
AOM can significantly affect hearing, particularly between 6 and 24 months of age, a critical period for language development. Chronic or recurrent disease may result in conductive hearing loss, which can impair auditory input and delay speech and language acquisition. These risks underscore recommendations from the AAP and the American Academy of Otolaryngology–Head and Neck Surgery for timely and appropriate management of recurrent AOM.
Consultations
Patients with uncomplicated AOM are typically treated by their primary care clinician, urgent care providers, or emergency department staff. Management may involve additional specialties when the disease becomes recurrent, persistent, or associated with complications. For example, if a patient experiences recurrent AOM or CSOM, primary care clinicians may refer them to an otolaryngologist for surgical options, such as tympanostomy tube placement.
Young children with CSOM may experience speech and language delays due to hearing loss associated with recurrent ear infections. If a child shows signs of hearing loss or has difficulty meeting language development milestones, an audiologist should become involved in their care. A speech-language pathologist may also be indicated to address persistent delays, particularly following tympanostomy tube placement.[63]
Deterrence and Patient Education
Patient education and preventive strategies play an important role in reducing the incidence and recurrence of AOM. Routine immunization with pneumococcal and influenza vaccines helps reduce upper respiratory tract infections, which often precede AOM. Caregivers should also minimize children’s exposure to secondhand and thirdhand tobacco smoke, which increases respiratory irritation and infection risk.
Feeding practices and environmental exposures also influence risk. Breastfeeding, when feasible, is associated with a lower incidence of otitis media due to the transfer of protective immunoglobulins. Additional measures include good hand hygiene and limiting exposure to individuals with respiratory infections.
Caregiver education should also address symptom recognition and appropriate care-seeking. Persistent fever, worsening ear pain, or changes in hearing or behavior warrant medical evaluation. Adherence to treatment plans and follow-up recommendations supports optimal outcomes and helps prevent complications.[64]
Pearls and Other Issues
The following clinical pearls summarize key principles in the diagnosis and management of AOM, emphasizing evidence-based criteria, appropriate antibiotic use, and indications for procedural intervention. These points highlight common pitfalls in diagnosis, reinforce guideline-directed therapy, and support clinical decision-making across a range of care settings.
Diagnosis
Diagnosis of AOM may be based on:
- Tympanic membrane bulging and erythema
- Otorrhea not caused by acute otitis externa
- Signs and symptoms such as pain, fever, hearing loss, and ear holding, tugging, or rubbing
Diagnosis of AOM should not be made when pneumatic otoscopy and tympanometry do not indicate middle ear effusion.
Treatment
Treatment for AOM must include pain and fever management. Amoxicillin is the antibiotic of choice, unless:
- The child has received it within the past 30 days
- The child has concurrent purulent conjunctivitis
- The child is allergic to penicillin
In these cases, an antibiotic with additional β-lactamase coverage should be given.
Additional pearls regarding antibiotic therapy include:
- If antibiotics are deferred in favor of watchful waiting, a contingency plan for antibiotics should be established.
- Pediatric infections that do not respond to initial antibiotic therapy within 48 to 72 hours should be reevaluated for a change in treatment.
- Prophylactic antibiotics are no longer advised for children experiencing recurrent AOM; instead, patients should be evaluated for tympanostomy tube placement.
Tympanostomy and Tube Placement
- Tympanostomy tube insertion should not be performed in children with recurrent AOM who do not have middle ear effusion in either ear at the time of assessment for tube candidacy.
- Bilateral tympanostomy tube insertion should be performed in children who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy.
- Clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea.[65]
Enhancing Healthcare Team Outcomes
To provide effective, patient-centered care for individuals with AOM, a collaborative approach among healthcare professionals is essential. This team typically includes clinicians, advanced practice practitioners, audiologists, nurses, pharmacists, and speech-language pathologists.
Clinicians and advanced practice providers need the clinical skills and expertise to accurately diagnose, evaluate, and treat this condition, as AOM can resemble other diagnoses. Clinicians may face challenges in treatment, including the potential overuse of antibiotics, as many cases are viral rather than bacterial. Proficiency in pneumatic otoscopy, the ability to recognize potential complications, and an understanding of the nuances in management and prevention are critical for improving patient care. Newer technologies that support interprofessional teams in outpatient settings, such as video otoscopy, have shown promise in improving timely diagnosis and treatment.
A strategic, collaborative approach that integrates evidence-based guidelines with personalized care plans is particularly vital when AOM becomes recurrent. This methodology allows for the tailoring of treatment to each patient's unique needs. Ethical considerations are crucial in selecting treatment options and in respecting the dynamics of decision-making among patients and their families. Clinicians often encounter parents of children who express frustration regarding the recommendation of watchful waiting as opposed to immediate antibiotic therapy. These concerns are compounded by the potential for hearing loss in children, as well as complications such as speech delays, social disruptions, and educational challenges that are associated with recurrent infections. Clinicians should engage in conversation to support shared decision-making.
Early diagnosis and prompt treatment can reduce the risk of complications, thereby improving patient outcomes. Nurses instruct families about medication administration, supportive care, and analgesics, and they review follow-up instructions. Pharmacists educate patients about the potential adverse effects of medications and check for drug interactions. Audiologists may guide the monitoring of the child's hearing. Referrals to otolaryngologists might be needed, especially for recurrent or chronic infections or possible complications.
Media
(Click Image to Enlarge)
Acute Otitis Media Pathophysiology. This illustration shows the common etiologies and pathophysiology of acute otitis media.
Shutterstock
(Click Image to Enlarge)
Acute Otitis Media on Otoscopy. This otoscopic image shows tympanic membrane erythema and bulging, consistent with acute otitis media.
B Welleschik, Pubic Domain, via Wikimedia Commons
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