Acute Otitis Media (AOM)

Acute Otitis Media (AOM)

A 16 month-old child is brought into the emergency department (ED) for evaluation of congestion, cough, and fever.  The parents report the child has had nasal congestion and cough for the past 4 weeks with an occasional “day or two” of improvement.   They are concerned because he has seemed chronically congested ever since starting daycare a little over a month ago.  He was seen in the urgent care (UC) earlier in the evening and diagnosed with sinusitis.  The UC also noted, “fluid behind ears without bulging.”  Covid, influenza, and RSV tests were all negative, so he was sent home with a prescription for an antibiotic to treat presumed sinusitis.  The child seemed irritable after returning home, so his parents decided to have him evaluated again.

Physical exam was notable for a well-appearing child with copious nasal drainage and clear lungs without any increased work of breathing.  Wispr otoscopic exam revealed the following from the right ear.

The child has acute otitis media (AOM).

The case of the Congested Daycare Attendee has become a common theme over the past few months as increasing numbers of children return to daycare after missing out on natural immunity exposures during the height of the Covid pandemic.  Fortunately, most cases of “continuous congestion” are simply uncomplicated overlapping viral URIs requiring parental reassurance and supportive measures.  However, most clinicians recognize that co-infections are common, particularly when signs or symptoms are prolonged or worsening beyond the usual URI time course of 5-7 days.

A PubMed search reveals multiple investigations demonstrating that acute otitis media (AOM) frequently accompanies URIs.  The key features of AOM include loss of malleus definition, bulging, and to lesser extent erythema. While the primary pathogenesis is felt to be secondary to Eustachian Tube (ET) dysfunction which decreases the ability to clear nasopharyngeal bacteria from the middle ear space, anatomic characteristics of short, horizontally-oriented ETs as well as their multitude of viral exposures make young children particularly vulnerable.  In fact, a 2007 study published in Pediatrics, found that AOM occurred in 30% of pre-school-aged children with URI symptoms1.  Thus, in our patient with URI symptoms and bulging on Wispr exam (likelihood ratio of 51), there is a whopping 97% probability of AOM.    While it is less certain that he has sinusitis as diagnosed earlier in the night, an antibiotic was clearly warranted to treat his AOM.

Here is the video of the complete exam. Note that only a brief “flash” of the bulging ear drum is seen. This shows the power of the Wispr otoscope. Using video mode of the Wispr otoscope, the provider can focus on the exam without having to “process” what is being seen. Reviewing and scrubbing the video afterwards isolates the image of interest, clearly showing AOM.

Complete exam video


Krystal Revai et al.   Incidence of acute otitis media and sinusitis complicating upper respiratory tract infection: the effect of age Pediatrics. 2007 Jun;119(6)