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An American Academy of Pediatrics State Chapter organized a 6-month, mostly online quality improvement learning collaborative to improve antibiotic prescribing and patient education for upper respiratory infection (URI) and acute otitis media (AOM). Practices submitted data on quality measures at baseline, monthly, and 4 months post-project. Fifty-three clinicians from 6 independent, private primary care pediatric practices participated. Use of first-line antibiotics for AOM increased from 63.5% at baseline to 80.4% 4 months post-project. Use of safety-net antibiotic prescriptions (SNAP) for AOM increased from 4.5% to 16.9%. Educating patients about management for URI increased from 66.1% to 88.0% and for AOM from 20.4% to 85.6%. Practices maintained high performance for not prescribing antibiotics for URI (94.4% to 96.2%). Leveraging local relationships and national resources, this replicable antibiotic stewardship project engaged independent private practices to improve patient education for URI and AOM and prescribing and use of SNAP for AOM. [ABSTRACT FROM AUTHOR]

Pediatric antibiotic prescriptions originate from an increasingly broad range of ambulatory settings. In this retrospective study, pharyngitis, otitis media, sinusitis, pneumonia, and upper respiratory infection cases, at 11 primary care offices, 2 independent urgent care centers (UCCs), and a pediatric emergency department in Western New York, were analyzed relative to medical society practice guidelines and antibiotic utilization. Of 2358 eligible visits across all sites, 25% were for study diagnoses, with 38% at UCC (P <.01). Across all sites, 26% of pharyngitis cases given antibiotics did not have diagnostic evidence of bacterial infection. At primary care offices and UCCs, guideline recommended first-line agents for pharyngitis and otitis media were used in only 58% and 63% of treated cases, respectively. Overall, an estimated 9855 to 12 045 avoidable antibiotic and 8030 non-guideline antibiotic courses annually are represented by the 14 sites studied. These and other study findings highlight numerous opportunities for outpatient pediatric antibiotic stewardship. [ABSTRACT FROM AUTHOR]

Acute otitis media (AOM) is a leading cause of health encounters and antimicrobial prescriptions in children worldwide. We assessed (1) the rates of antimicrobial prescribing by pediatric emergency department clinicians using a smartphone otoscope device as compared with a conventional otoscope and (2) clinician acceptability of the smartphone device. We conducted a randomized control study in children's hospital emergency departments over 6 months. More than 1500 encounters were analyzed. The odds of prescribing antibiotics after being given a diagnosis of AOM by clinicians assigned to the smartphone group was 11% higher than the conventional group (18.8% vs 18.0%, odds ratio = 1.106, P = .600). Eight (73%) of the 11 physicians in the smartphone group preferred the smartphone device over the conventional otoscope. Use of a smartphone otoscope for detection of AOM in a pediatric emergency department setting did not lead to an increased likelihood of AOM diagnosis. [ABSTRACT FROM AUTHOR]

Acute otitis media (AOM) is a common childhood illness. The aim of this study was to assess whether AOM in the first month of life predicts recurrent AOM (rAOM) in early childhood. The medical records of all neonates with AOM and isolation of bacterial pathogen from middle-ear fluid during 2005-2010 were reviewed. Neonates without AOM admitted during the same period for neonatal fever workup were included as controls. Information regarding rAOM and possible risk factors were collected through a phone interview with the parents. A total of 84 neonates with AOM were enrolled; 25 (30%) had rAOM compared with 8/79 (10%) in the control group. Neonatal AOM increases 4-fold the odds of rAOM later in childhood (odds ratio = 4; 95% CI = 1.44-11.42; P = .008), independent of smoke exposure, numbers of siblings, AOM in siblings, breastfeeding, day care attendance, or use of pacifier. Neonatal AOM is a significant risk factor for rAOM during infancy. [ABSTRACT FROM AUTHOR]

We determined the cost of care for 2 diagnosis and management approaches for acute otitis media (AOM) among children 6 to 30 months old. A case–control design was used. Cases included 208 children diagnosed with AOM based on a bulging tympanic membrane (TM) and treated with amoxicillin/clavulanate. Controls (5:1 ratio) included 1020 children with AOM diagnosed not requiring bulging of the TM and treated with amoxicillin. Fewer cases (49%) than controls (69%) were diagnosed with AOM (P < .001), fewer were diagnosed with recurrent AOM or AOM treatment failure (0.34 vs 1.6/child; P < .0001), and fewer had insertion of tympanostomy tubes (6.3% vs 14.8%) due to recurrent AOM (P < .0001). The combined direct payments and indirect costs for management of AOM were $539/case versus $1,023/control. Using Rochester NY payments generalized to the US birth cohort, this case diagnosis and treatment strategy could save $1.008 billion per year. [ABSTRACT FROM PUBLISHER]

Objective. To evaluate an easy to use 10-point scoring system in clinical assessment of acute otitis media (AOM). Study design. Symptoms of AOM observed by validated otoscopists were tabulated and scored with a 10-point and a 30-point system at acute onset of illness and at the test-of-cure (TOC) 3 weeks later. Results. A total of 330 children (mean age = 13.1 months) with AOM were studied. At AOM onset, the mean 10-point and 30-point scores; were highly correlated (P < .001). At TOC, 256 children were cured, 69 failed, and 5 were lost to follow-up. The 10-point scores were 0.5 and 4.4 for children with cure and failure. The 10-point score had a sensitivity of 87%, specificity of 98%, positive predictive value of 91%, and negative predictive value of 97% compared with the diagnosis by validated otoscopists. Conclusion. A simple, easy-to-use 10-point AOM scoring system was shown to discriminate AOM cure and failure at TOC. [ABSTRACT FROM PUBLISHER]

Objective. To describe the pain associated with diagnostic tympanocentesis and to gather preliminary data comparing the efficacy of 3 methods of pain reduction for tympanocentesis. Methods. In children 6 to 36 months of age undergoing tympanocentesis for acute otitis media, the authors measured pain and distress throughout all phases of the procedure and recovery using physiological (heart rate) and behavioral measures (cry duration, Global Mood Scale score, and pain visual analog scales). They compared—in a randomized controlled trial—3 pain reduction interventions: acetaminophen, acetaminophen plus codeine, and ibuprofen plus midazolam. Results. Heart rate increased throughout the procedure, peaking during needle aspiration. Children treated with acetaminophen alone had higher peak heart rates and Global Mood Scale scores during parts of the procedure. Conclusions. Acetaminophen alone may not be as effective in reducing pain-related physiological and behavioral changes as acetaminophen plus codeine or ibuprofen plus midazolam during diagnostic tympanocentesis. [ABSTRACT FROM PUBLISHER]

In an era of increasing antibiotic resistance, reliance on empirical antibiotic therapy for management of acute otitis media (AOM) will eventually become an untenable strategy. New research efforts are needed to identify effective treatment alternatives. In this retrospective analysis, we assessed AOM treatment failure (AOMTF), recurrent AOM (RAOM), and antibiotic prescription rates for groups of AOM episodes managed with either immediate antibiotics (ABX), tympanocentesis + observation (Tap + OBS), or tympanocentesis + immediate antibiotics (Tap + ABX). No significant differences in rates of AOMTF or RAOM were observed between any of the treatment groups. The 30-day rate of antibiotic prescriptions written for AOM was significantly lower in the TAP + OBS group (1 prescription per 3.8 episodes) than in the immediate antibiotic therapy groups (1.2 prescriptions per episode), P < .001. The comparative risk of AOMTF was slightly higher among AOM episodes caused by Streptococcus pneumoniae (OR 2.523; CI 1.070-5.944; P = 0.056). Neither the presence of other particular otopathogens, nor the presence of drug-resistant otopathogens, nor the choice of any particular AOM antibiotic therapy correlated with increased risk of either AOMTF or RAOM. The observed absence of significant differences in clinical outcomes between the various treatment groups in this study is consistent with findings published by other authors: alternative AOM therapies can help reduce reliance on antibiotics without inviting significant increases in rates of clinical failure. [ABSTRACT FROM AUTHOR]

This review of electronic patient records was conducted to identify trends in acute otitis media (AOM) microbiology in the Puget Sound region. Culture results from tympanocentesis procedures performed between July 1, 2005 and June 30, 2009 were compiled into 4 respiratory disease seasons: 2005-2006, 2006-2007, 2007-2008, 2008-2009. Heptavalent pneumococcal conjugate vaccination coverage within the cohort was 85%; average patient age was 13 months (SD = 6.6). The proportion of AOM isolates positive for Streptococcus pneumoniae for the four periods covered was 48%, 41%, 35%, and 54%, respectively (P = 0.185, 3rd to 4th season). For Haemophilus influenzae, the proportions were 42%, 41%, 59%, and 38%, respectively (P = 0.182, 3rd to 4th season). Penicillin resistance among S pneumoniae isolates increased from 13% to 61% across the study period (P = 0.016). S pneumoniae may be regaining prevalence as an otopathogen in PCV7-vaccinated populations, and levels of penicillin resistance are increasing. [ABSTRACT FROM AUTHOR]

Although the incidence of acute mastoiditis has been substantially reduced since the introduction of antibiotic therapy, mastoiditis complications are still commonly seen in the pediatric population. Many of these cases require lengthy hospitalizations and extensive medical and surgical interventions. Accordingly, a safe, effective, and resourceful diagnostic and therapeutic plan must be executed for the workup and treatment of each patient suspected of having acute mastoiditis. With thorough clinical evaluations, early diagnosis, and close follow-up, a large proportion of children with severe acute otitis media or early stage mastoiditis can be managed in the primary care setting without immediate surgical specialty involvement. This review presents an overview of the anatomical and pathophysiological considerations in acute mastoiditis and offers pediatricians a practical, evidence-based algorithm for the diagnostic and therapeutic approach to this disease. [ABSTRACT FROM AUTHOR]

This study sought to determine the microbiology of recurrent acute otitis media (AOM) and AOM treatment failure (AOMTF) in the context of widespread use of heptavalent pneumococcal conjugate vaccine (PCV7). In this retrospective cohort study, 244 AOM isolates obtained by tympanocentesis during 3 respiratory seasons-2003-2004 (n = 126), 2004-2005 (n = 52), 2005-2006 (n = 66)--from three geographically diverse pediatric populations were compared. Most isolates were from children less than 2 years old, who had received PCV7. For the 3 seasons the proportion of Streptococcus pneumoniae isolates was 35%, 35%, and 46% and for Haemophilus influenzae was 55%, 58%, and 39%, respectively (change in trend, P = .09). A total of 37%, 39%, and 50% of S. pneumoniae were penicillin nonsusceptible (PNSP) and 48%, 67%, and 50% of H. influenzae produced β-lactamase, respectively. Although H. influenzae remains the most frequently isolated pathogen in children with AOMTF or recurrent AOM, S. pneumoniae that are PNSP are reemerging as important organisms. [ABSTRACT FROM AUTHOR]

Clinicians use various criteria to diagnose acute otitis media (AOM). Using American Academy of Pediatrics (AAP) guidelines, we reviewed the consistency of AOM diagnosis in clinical trials (1994–2005). Eighty-one percent of the studies required at least one of the three AAP criteria. Only 20% of the 88 studies met all three AAP criteria for a diagnosis. We found no association between the number of criteria met and study quality or industry sponsorship. Better agreement on the definition of AOM using AAP criteria could facilitate a more accurate clinical diagnosis and provide standardization of research and patient care practices. [ABSTRACT FROM AUTHOR]

Pediatricians can decrease antibiotic use by treating acute otitis media (AOM) with a safety-net antibiotic prescription (SNAP). This study assessed whether the practitioners of the Practice-Based Research Network who participated in the study continued to use the SNAP and report a 60-day follow-up of the study patients. Charts were reviewed of study patients for 60 days following study enrollment. A survey on antibiotic use for AOM was mailed to the 17 study practitioners (SP) and 30 randomly selected community pediatricians (CP). Eight of the SP used the SNAP more than 20 times over the year following the study vs 1 of the CE Sixty-two percent of patients never received antibiotics. The recurrence/relapse rate was greater in children younger than 2 years old compared to those older, 34% vs 10%. Practitioners who participate in a Practice-Based Research Network study are more likely to use a study intervention than others. [ABSTRACT FROM AUTHOR]

The article presents a case study on tuberculous (TB) otitis media. Usually children with chronic otorrhea are treated with variety of antibiotics. A delay in diagnosis and treatment of TB otitis media may lead to serious complications. This delay may lead to permanent morbidity such as hearing loss and other complications. The complications of TB otitis media include facial nerve palsy, necrosis of the ossicles, bony destruction of the mastoid, and bony destruction of the petrous bones. Periauricular fistulas, lymphadenopathy, and intracranial tuberculomas or abscesses are rare complications. It presents a case study of a 22-month-old boy who was suffering from persistent/recurrent suppurative otitis media. He was referred to an infectious disease specialist for its evaluation. In case of a patient, particularly an immigrant, refugee, or international adoptee, who presents with otitis media or otorrhea and does not respond to usual therapy, TB otitis should be considered. It highlights that the treatment of TB should be initiated even in the absence of pathogen isolation. The aim is to avoid permanent hearing loss.

The diagnosis of acute otitis media is based on several clinical factors. One of these factors is the color of the tympanic membrane (TM). Crying can cause flushing and hyperemia of the face. The purpose of this study is to determine whether crying affects the color of tympanic membranes. Infants and toddlers (age 30 months or less) evaluated in an outpatient clinic or primary care pediatrician's office for routine well-baby checks who received at least 2 parenteral immunizations were enrolled on a convenience basis. Ill children were excluded. The initial physician assessed crying and TM color/visibility. Following immunizations, a second physician assessed crying and the TM color/visibility. Color differences were stratified by the degree of crying. One hundred twenty-one study subjects received 2-5 parenteral immunizations. TM colors were most often in the pink range or less. Only 2 TMs were assessed as light red and none were assessed as red. Twenty-eight percent of the TMs with greater crying on the second exam were noted to be redder on the second exam compared to the first exam versus 11% for the comparison group (p=0.0007); 19% of the TMs with greater crying on the second exam were noted to be redder by 2 or more increment levels compared to the first exam versus 5% for the comparison group (p=0.0004); 31% of the TMs with greater crying on the second exam at the 3+ and 4+ level were noted to be redder on the second exam compared to the first exam versus 14% for the comparison group (p=0.003). Our data indicate that, in some instances, crying can result in an increase in pinkness of the TM. Crying in well children does not result in a red tympanic membrane. [ABSTRACT FROM AUTHOR]

The article examines the role of cephalosporins for the treatment of acute otitis media (AOM) in this era of increasing antimicrobial resistance among common respiratory tract pathogens. AOM is the most common reason that antimicrobials are prescribed for children in the United States. The study indicates that the current role of cephalosporins in therapy is not clear. Further investigation is warranted before an accurate determination of which patients with AOM may be appropriately treated with a cephalosporin can be made.

We surveyed pediatricians (PEDs), family physicians (FPs), otolaryngologists (ENTs), and emergency physicians (ERs) from across Michigan (100 each), as well as 30 nationally recognized experts about their clinical approach to acute otitis media (AOM). The overall response rate was 52%. There was substantial variation within each group with respect to diagnostic criteria and clinical decision-making, but no significant differences among groups. The 63% of respondents who considered symptoms among their diagnostic criteria for AOM were 3.8-fold more likely to defer therapy for an asymptomatic toddler with a bulging, red, immobile tympanic membrane (TM) (95% Confidence Interval (CI) 1.53, 9.74), but 24% of respondents stated that they would prescribe oral antibiotics for a symptomatic child with a red TM, even in the absence of a middle ear effusion. These data suggest that diagnostic criteria are a major factor determining whether clinicians prescribe antibiotics to a particular patient. [ABSTRACT FROM AUTHOR]

Provides consensus recommendations for the management of acute otitis media (AOM) that pediatricians can incorporate into their daily practices. Epidemiology of AOM; Pathogenesis of AOM; Recommendations for practitioners for the management of AOM.

Examines serial measurements by tympanometry and reflectometry in children with clinical acute otitis media (AOM) at the time of diagnosis, 3 to 5 days later, and at final follow-up 12 to 15 days after diagnosis. Evolution of instrumental findings; Identification of unique patient subpopulations with differing prognoses.

We report a study of the feasibility of once-a-day amoxicillin to treat acute otitis media (AOM). Seventy-seven children between ages 7 months and 12 years with AOM participated in a double-blind, placebo-controlled trial. Subjects received amoxicillin 40 mg/kg/day for 10 days. They were similar in age, sex, history of ear infections, and presenting symptoms. Group I received one total dose of amoxicillin and two doses of placebo daily. Group II received three divided doses of amoxicillin daily. Parents kept a daily diary of symptoms related to the child's illness and possible medication side effects. Ten children were lost to follow-up. In the remaining 67, pneumatic otoscopy and tympanometry after 10 to 14 days revealed that AOM had resolved in 82% of group I and 68% of group II. Groups showed no significant differences in persistence of middle ear effusion; 39% in group I and 24% in group II still had fluid. Diaries showed no significant differences between groups in medication side effects. Thus, reduced-frequency dosing for AOM seems feasible and more realistic than current regimens. [ABSTRACT FROM AUTHOR]

The article reports that acute otitis media is the most common infection in childhood; 75% of children experience at least one episode in childhood. Rarely, it can be a manifestation of an underlying immunodeficiency, in particular a neutrophil-function disorder. Although neutrophil-function disorders are uncommon, they must be considered in any child presenting with recurrent bacterial infections, particularly pyogenic infections involving multiple sites in association with other abnormalities, such as persistent leukocytosis and failure to thrive or a significant family history of infections. Polymorphonuclear leukocytes, or neutrophils, play a major role in the defense against acute bacterial infection. Neutrophils, stimulated by chemotactic factors released by bacteria, adhere to endothelial cells and migrate through basement membrane to sites of infection, where engulfment and oxidation of the bacteria take place. Disorders in neutrophil function may occur at any stage in this process and characteristically present with recurrent and potentially life-threatening bacterial or fungal infection. Early recognition of these disorders is important in order to provide appropriate management and treatment.

The author reviewed the potential risks of trimethoprim-sulfamethoxazole (TMP-SMX) treatment in children so that a more educated decision can be made in the choice of a prophylactic drug for recurrent acute otitis media, particularly in the penicillin (ampicillin, amoxicillin) allergic child. [ABSTRACT FROM AUTHOR]

Patients with recurrent otitis media without persistent middle ear effusion were studied for antibiotic prophylaxis efficacy. In the first phase, erythromycin ethylsuccinate was used as prophylaxis for otitis media in 45 patients in a dose of 10 mg/kg twice daily. Acute otitis media occurred in eight of 45 (18%) while receiving erythromycin, and in 22 of 41(54%) following prophylaxis termination. The attack rate (episodes of otitis media per 2-month period) was 0.86 before prophylaxis, 0.20 during prophylaxis, and 0.79 following prophylaxis. In a second phase of the study, erythromycin was compared with sulfisoxazole for otitis media prophylaxis in a group of 42 children. Sulfisoxazole (500 mg per dose) was administered twice daily. Acute otitis media occurred in five of 28 (18%) children while receiving erythromycin and in nine of 21(43%) children while receiving no prophylaxis. The attack rate (episodes of otitis media per 2-month period) was 0.81 before erythromycin prophylaxis, 0.18 while receiving erythromycin, and 0.50 after erythromycin prophylaxis. Acute otitis media occurred in eight of 14(51%) children while receiving sulfisoxazole, and in two of five (40%) children while receiving no prophylaxis. The attack rate (episodes of otitis media per 2-month period) was 0.78 before sulfisoxazole, 0.72 while receiving sulfisoxazole, and 0.56 after sulfisoxazole prophylaxis. Erythromycin antimicrobial prophylaxis for children with recurrent otitis media was superior to no prophylaxis and to sulfisoxazole prophylaxis in this study of patients with recurrent otitis media without persistent middle ear effusion. [ABSTRACT FROM AUTHOR]

Presents a retrospective review of clinical experience with the diagnosis of acute otitis media (AOM) in children. Age-specific patterns of diagnosis; Variation in the rates of diagnosis; Implications of the study's findings on clinical practice, health planning and pediatric research.

The article describes how myringotomy can be utilized to control acute otitis media with or without mastoiditis, as well as to provide adequate surgical drainage when needed. Indications for myringotomy are either diagnostic or therapeutic. Diagnostic myringotomy should be considered in any infant with fever of undetermined origin whose tympanic membrane is not absolutely normal. Therapeutic indications for myringotomy include acute otitis media with severe pain, acute or chronic otitis media which fails to respond to antibiotic therapy and recurrent episodes of otitis at short intervals. Techniques of myringotomy are: restraining the patient, sedation, instrumentation and incision.

This article examines newer attitudes toward the treatment of acute otitis media. Since the advent of antibiotics, most children with otitis media respond to treatment in a rapid and satisfactory fashion. And the clinical responses to different treatment programs have been evaluated by a group of researchers at the Mayo Clinic. Good results were achieved with a great variety of drugs. Only penicillin with an added sulfonamide was statistically superior to tetracycline used alone. A single injection of long-acting penicillin seemed adequate treatment, with a failure rate of only 5.1 percent.

In a controlled clinical trial, 154 children with 158 episodes of acute otitis media were treated in random distribution with a penicillin, a tetracycline, or a sulfonamide preparation. Cultures obtained of pharyngeal swabs from all children and of the ear exudate in children with purulent otitis media were not helpful in assessing the potential merits of antimicrobial therapy. There was little correlation of microbiologic results in cultures obtained from both sites. Treatment with penicillin or tetracycline proved superior to that with a so-called sustained-release form of sulfonamide, particularly in patients having purulent otitis media. No mastoiditis occurred. [ABSTRACT FROM AUTHOR]

Summarizes the results of studies relating to pediatrics. Long-term effects of inhaled antiinflammatory drugs, budesonide and nedocromil, in children; Prevention of acute otitis media during viral upper respiratory infection in children; Clinical and immunologic characteristics of patients positive and negative by fluorescence in situ hybridization.

Presents a retrospective study to examine the age distribution of Myringitis bullosa. Review of medical records of patients less than 17 years old between September 1987 and September 1990; Myringitis bullosa as an acute otitis media variant (AOM); Comparison of Myringitis patients' mean age with AOM patients' mean age; Prevalence of Myringitis bullosa's occurrence in older patients.

This article discusses various issues related to chronic middle ear effusion as a possible cause of protracted vomiting and of failure to thrive in infancy. The article presents a case report in this regard. Protracted vomiting in infancy presents a major diagnostic problem that entails consideration of infectious causes, anatomic lesions, endocrinopathies and neurometabolic disorders. Chronic otitis media with effusion, regarded as one of the most common chronic disorders in childhood, is not included among the numerous conditions associated with vomiting. The article authors describe three infants who suffered from persistent vomiting with failure to thrive and who had undergone lengthy and extensive in-hospital evaluation prior to recognition of chronic middle ear effusion as the cause of their symptoms. Vomiting is a common manifestation of acute otitis media, during which an inflammatory response of serous labyrinthitis is believed to occur. As effusion in the middle ear can cause tinnitus, sensorineural hearing loss and even vertigo, symptoms attributable to inner ear stimulation, it would not be surprising that vomiting would also occur as part of the clinical presentation of chronic otitis media with effusion.

Cefaclor was used to treat 13 children with acute otitis media caused by ampicillin-resistant strains of Hemophilus influenzae. The children were re-examined on days 4, 10, and 28. Pharmacologic compliance was assessed by means of a bioinhibition assay on a urine specimen obtained on days 4, 7, and 10. Nine of the 13 children had evidence by tympanogram of residual otitis media with effusion (secretory otitis media). Of these, three were noted to have a bulging, yellow or grey eardrum, which suggested an ongoing acute process. A second middle ear culture was obtained from two of the 3 children, but no pathogens were recovered. Two others had recurrence of otitis shortly after cessation of therapy. Cefaclor is an acceptable antibiotic for the treatment of ampicillin-resistant acute otitis media; but, after cefaclor therapy, some children continued to have a bulging eardrum and sterile pus in the middle ear or had recurrences of otitis soon after cessation of therapy. [ABSTRACT FROM AUTHOR]

Of 429 children with acute otitis media who returned for follow-up evaluation, 49 (11%) were unresponsive to a 10- to 14-day course of ampicillin, amoxicillin, or erythromycin/sulfisoxazole. Patients with persistent purulent otitis media were noted to have immobile, bulging, yellow or grey, abscessed tympanic membranes at the follow-up visit. A myringotomy was performed on 45 children. Cultures of middle-ear exudate yielded ampicillin-resistant Haemophilus influenzae in 14 (31%), ampicillin-susceptible pathogens (H. influenzae or Streptococcus pneumoniae) in 23 (51%), and no growth in 8 (18%). [ABSTRACT FROM AUTHOR]

Acute otitis media, though one of the most frequent infectious disease problems in childhood, still presents great challenges in determining the etiology, pathogenesis and treatment. Five to 10 per cent of patients with acute otitis media have extremely severe pain with a bulging tympanic membrane. The median body temperature in patients with sterile otitic fluid was higher than those whose specimens yielded pathogenic bacteria. When considering therapy, other factors to be kept in mind when determining whether or not to give antibiotic therapy are the clinical status of the patient, leucocyte count, past history, and the infectious diseases prevalent in the community at the time the patient is seen. It is recommended that children with acute otitis media who are three years or less be treated with penicillin by mouth in dosage from 200,000 to 400,000 units every six hours.