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Middle ear fluid from AOM cases often harbour both viruses and bacteria; however, children who experience spontaneous resolution of AOM are likely to have viral infections alone or to have bacterial organisms that are less virulent (eg, Moraxella catarrhalis and some strains of Haemophilus influenzae ) compared with Streptococcus pneumoniae and Streptococcus pyogenes (group A streptococci [GAS]).[10] In one prospective study, 22% of children between six months and three years of age developed AOM during the first week of an upper respiratory infection, while a further 7% had myringitis without effusion.[11] Thus, the clinical presentation of AOM can vary with the stage of illness (early versus later).

Also, children may amoxil for cough or may not progress to overt bacterial AOM depending on which viruses or bacteria are present in the nasopharynx.[12] Bacteria commonly associated with AOM. The most common bacteria causing AOM are S pneumoniae, H influenzae, M catarrhalis and (less commonly) GAS.

Usually there is a single bacterial pathogen but coinfection can occur.

Studies following the routine use of the seven-valent conjugated pneumococcal vaccine (PCV7) demonstrated the increasing importance of nonvaccine type S pneumoniae and non-typable H influenzae .[13] However, more recent studies performed during the 13-valent pneumococcal vaccine era have shown lower carriage rates for S pneumoniae overall.[14] It is not yet known whether the absolute number or only the percentage of cases of AOM due to H influenzae and M catarrhalis will increase with the widespread use of the 13-valent conjugated pneumococcal vaccine (PCV13). It has been estimated that the routine use of PCV7 in Canada has decreased the incidence of AOM by 13% to 19% because nasopharyngeal colonization with vaccine-type S pneumoniae in children has been

significantly

A bulging TM had a high specificity (>97%) but a lower sensitivity of 51%, while a cloudy TM also had high specificity (93%) with a good sensitivity (74%) for the presence of MEE and clinical symptoms of AOM.

Other studies have also indicated that a bulging TM has a higher specificity for the presence of S pneumoniae and other bacteria, regardless of the presence of viruses, and is associated with more severe illness.[10][29] In addition to a bulging TM, it was noted that when the TM was yellow, a bacterial pathogen could be cultured 80% of the time.[30] Using a convenience sample of 264 ill children presenting to primary care with typical AOM symptoms, experienced otoscopists wanted to determine and validate which sign was the best predictor of AOM. They concluded that all children with bulging TMs and only 8% of those with non-bulging TMs had AOM, making bulging the most important criteria for the diagnosis.[32] Other features, such as hemorrhagic patches or erythematous TM, had poor interobserver agreement, while erythema, opacity or air fluid levels alone – without a bulging TM – had poor predictive value.[29][32] Therefore, a bulging TM is a very sensitive and specific indicator for acute inflammation consistent with AOM. Similarly, an acute perforation with purulent discharge (otorrhea) in the setting of AOM strongly supports a bacterial cause.

Although S pneumoniae is the most common cause of AOM, several studies have isolated S pyogenes in a higher percentage of patients who have spontaneous perforations compared with patients whose TMs remain intact.[33] Importantly, amoxicillin and metronidazole for gum infection the drainage associated with acute symptoms of AOM and perforation should always be distinguished from otitis externa, chronic ear drainage from a previous perforation (with no middle ear inflammation) or drainage associated with a tympanostomy tube, because management for these conditions would be very different.

Clinical features not consistent with AOM are a TM with normal or slightly reduced mobility, or a non-bulging TM with or without erythema or cloudiness. Air-fluid levels alone, without a bulging TM, are not predictive of AOM. An excellent video describing otoscopy technique

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Very rarely, at initial presentation of AOM, infection has already progressed to involve adjacent structures.[35] In some cases, other associated signs or symptoms will predominate. All with spread beyond the middle ear should receive systemic antimicrobial therapy and an evaluation to consider surgical intervention and/or imaging to delineate the extent of the infection. The most common complication of AOM is acute amoxicillin for tooth extraction mastoiditis.

Although AOM is usually accompanied by inflammation of the mastoid air cells (including radiographic changes on computerized tomography), clinical symptoms, such as pain or swelling over the mastoid bone (behind the ear), suggest mastoiditis.

Other less common but clinically important syndromes associated with AOM are acute facial (cranial nerve VII) nerve palsy, which is also associated with temporal bone inflammation, or sixth cranial nerve palsy (failure of ipsilateral eye abduction) due to petrous bone inflammation or infection (Gradenigo’s syndrome).

Additional complications may include labyrinthitis, when infection spreads to the cochlear space, venous sinus thrombosis of the transverse, lateral or sigmoid venous sinuses, and meningitis.