To the Editor.—The articles by Dr Paradise1and Drs Culpepper and Froom2
were thought-provoking but both miss an important point well known to those
of us "in the trenches" seeing children every day with a diagnosis of otitis.
That is, otitis media (OM) has several different presentations in children,
different enough to almost make one consider them different diseases. The
categories are as follows: (1) the older child with upper respiratory infection
(URI) symptoms for a few days, who develops severe ear pain in the evening
or night, but is free of pain the next morning, with gross pus behind the
tympanic membrane; (2) the very young infant (younger than 3 months) who presents
with cold symptoms, slight fussiness, and thick fluid behind the tympanic
membrane; (3) the child with URI symptoms, who develops severe toxic effects
and high fever and looks very ill with acute otitis media (AOM); and (4) the
young child (6 months to 4 years) who attends day care and has nearly constant
URI symptoms throughout the year, with exacerbations from November to May
(in the Mid-Atlantic states). These children frequently have clear-to-thick
fluid behind the tympanic membrane all the time, but are frequently brought
to the physician with an exacerbation of symptoms (fever, waking up at night,
irritability, decreased appetite) and are found to have gross pus behind the
tympanic membrane. Antimicrobials seem to help the exacerbation of symptoms,
but do nothing to help the constant clear fluid.
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