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Controversies: Treatment of Acute Otitis Media

Michael J. Harkness, MD
JAMA. 1998;279(22):1783-1785. doi:10.1001/jama.279.22.1783.
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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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