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The Rational Clinical Examination
David L. Simel, Drummond Rennie
Otitis Media, Child
Russell Rothman, Thomas Owens, David L. Simel
In a study of 279 children with AOM, 29% required cerumen removal to make a proper diagnosis....


Topics Discussed: diagnostic process, otitis, otitis media, otitis media, acute, pediatrics, tympanic membrane, tympanostomy

Excerpt: "Acute otitis media can be a difficult and controversial diagnosis to make, but studies suggest that AOM is responsible for more than 30 million clinic visits a year in the United States, at a total cost exceeding $5 billion. This makes AOM one of the most commonly diagnosed and expensive childhood illnesses.1-4 Studies have shown that by age 1 year, up to 60% of all children have been diagnosed as having at least 1 episode of AOM, and by age 3 years, more than 80% of children have had at least 1 episode.1,5 The best estimates of the prevalence of AOM are based on the National Ambulatory Medical Care Survey. In 1990, the percentage of office visits with otitis media as the principal diagnosis was 17.4% for children aged 0 to 2 years, 18.1% for children aged 2 to 5 years, 10.5% for children aged 6 to 10 years, and 5.2% for children aged 11 to 15 years.6 The most common potential risk factors for diagnosis of AOM include age younger than 2 years, male sex, day care attendance, fall or winter season, exposure to cigarette smoke, genetic factors, and history of AOM.1,7 Breastfeeding appears to be protective.7Genetic, infectious, immunologic, and environmental factors contribute to an underlying predisposition to ear infections.2 The eustachian tube, shorter and angled much less steeply in children than in adults, plays a critical role by more easily allowing the reflux of organisms from the nasopharynx into the middle ear.2 When the tube becomes congested, as it may with a viral infection in the upper respiratory tract, negative pressure within the middle ear causes secretions to accumulate, and this leads to the proliferation of pathogenic organisms. The bacterial agents most commonly identified in AOM include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.5 Coinfection with viruses is also observed in 30% to 40% of cases and may play a role in the virulence of symptoms, but less than 10% of AOM is caused by viruses alone.5,14,15 Most ear infections resolve without any specific treatment, so the exact role of bacterial or viral pathogens remains unclear...."
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