Emergency Medicine Grand Rounds

Updated March 2013

Otitis Media Keith Conover, M.D., FACEP

A cute otitis media is different than otitis media

with effusion (fluid in the middle ear, secretory otitis
media, serous otitis, glue ear) and chronic otitis media
media is rare in developed countries, because in about
1930 we started treating ear infections with antibiotics.
Before this, chronic otitis media was common, and often
(chronic suppurative otitis media). People usually get led to deafness and other complications.2
acute otitis media with, or after, a cold.1 Chronic otitis

Diagnosis of acute otitis media

A cute otitis media is fluid in the middle ear

combined with signs or symptoms of acute local or
systemic illness. The ear may hurt, or may drain fluid;
dysfunction, and not a bacterial
infection.1
Predictive
Value (%)
Color Position Mobility

A recent study recommended 99 Cloudy Bulging Distinctly impaired

or the patient may have fever.3 But the specifics for
you diagnose acute otitis media 99 Cloudy Bulging Slightly impaired
diagnosis are not so clear. In 26 clinical trials, there were
with two or more of
18 different sets of diagnostic criteria. One survey of 165 97 Cloudy Normal Distinctly impaired
pediatricians resulted in 147 different sets of criteria!4 decreased or absent TM 94 Distinctly red Bulging Distinctly impaired
The 2013 AAP-AAFP guideline The Diagnosis and Man- mobility,
94 Cloudy Normal Distinctly impaired
agement of Acute Otitis Media5 provides the following yellow or white discolor-
93 Slightly red Bulging Slightly impaired
advice on diagnosing otitis media, trying to standardize ation of the TM,
the diagnosis: 89 Distinctly red Normal Distinctly impaired
opacification of the TM
Clinicians should [emphasis added] diagnose acute 85 Slightly red Bulging Distinctly impaired
not due to scarring, and
otitis media (AOM) in children who present with visible bubbles or air-
83 Distinctly red Bulging Slightly impaired
moderate to severe bulging of the tympanic mem- fluid levels.9 47 Distinctly red Normal Slightly impaired
brane (TM) or new onset of otorrhea not due to
41 Slightly red Normal Slightly impaired
acute otitis externa. Another study correlated color,
position and mobility with 37 Cloudy Normal Normal
Clinicians may [emphasis added] diagnose AOM
in children who present with mild bulging of the acute otitis media (diagnosed 29 Normal Retracted Distinctly impaired

TM and recent (less than 48 hours) onset of ear with myringotomy).10 A cloudy 15 Distinctly red Normal Normal
pain (holding, tugging, rubbing of the ear in a TM, and a bulging TM, and 7 Slightly red Normal Normal
nonverbal child) or intense erythema of the TM. a TM with decreased mobil-
3 Normal Retracted Slightly impaired
ity (all three) correlated 99%
Clinicians should not [emphasis added] diagnose with acute otitis media (see 0.1 Normal Normal Normal
AOM in children who do not have middle ear effu- Table 1). You might want to
sion (MEE) (based on pneumatic otoscopy and/ get your own insufflation bulb
or tympanometry). (Welch-Allyn #23804), as it adds a lot to the accuracy of
Diagnosing a middle ear effusion is fairly easy. Do pneu- your diagnosis; I did. You need soft speculum sheaths to
matic otoscopy. Thats where you use a soft ear speculum make a good seal with the external ear canal. The ED or
(to get a seal with the ear canal), with an insufflation clinic should supply these, though most dont. I bought a
bulb attached to the otoscope, and puff air into the ear.
You look at the tympanic membrane (eardrum, TM) for
position, color, translucency, and mobility.3 In one study,
as confirmed by myringotomy (needle aspiration of the
middle ear to get fluid), pneumatic otoscopy was 93%
sensitive and 58% specific for effusion, which compares
favorably with tympanometry (see below) which was 90%
sensitive and 86% specific.6
A, Normal TM. B,TM with mild bulging. C,TM with moderate bulging. D,TM with severe bulging.
A 2004 clinical guideline on otitis media with effusion Courtesy of Alejandro Hoberman, MD.
(OME) says: Distinct redness of the TM should not be a
criterion for antibiotic prescribing because it has poor pre- box of 80 of each size of the Welch Allyn SofSeal sheaths,
dictive value for acute otitis media and is present in about 24330 (med) and 24320 (small), that fit the speculums of
5% of ears with OME.7 Screaming babies always have a the Welch Allyn Macroview otoscopes in every ED and
red TM, and removing wax often makes the TM red.8 clinic in which I have worked for the past 10 years. It cost
A retracted TM, which hurts, is from eustachian tube 1
 $44.50/box from schoolhealth.com. for diagnosing a middle ear effusion.
A machine that tells you if the patient has a middle ear Like using an insufflation bulb, tympanometry requires
effusion without digging the wax out of the ear of a an airtight seal; however, spectral gradient acoustic reflec-
squirming, screaming infant sounds good. Tympanom- tometry (SGAR), also known as acoustic reflectometry,
etry uses such a device to assess for middle ear effusion. does not. SGAR machines emit tones from 1.8 to 4.4
Since the early 1970s, tympanometers have been found kHz, and measure how much is reflected. As with tym-
in many ENT offices and pediatric offices and a few panometry, accuracy depends on how experienced you
Emergency Departments. Theyre easy to use, but results are,13 though SGAR is easier than tympanometry.9
are a bit hard to figure out. Basic tympanometers mea-
Neither tympanometry or SGAR is better than history,
sure how much of a 226 Hz musical tone reflects back
physical exam, and pneumatic otoscopy to diagnose
from the TM, as the air pressure in the external canal is
acute otitis media.14 As Combs writes: No technology
varied, both above and below ambient air pressure. More
can replace the careful history and otoscopic examina-
modern tympanometers use a pair of musical tones. The
tion by an experienced physician.15
tympanometer plots a pressure-versus-compliance curve
on a graph known as a tympanogram. The interpretation Physicians cant diagnose acute otitis media by symp-
of tympanograms is described in the medical literature toms alone. But parents can. Their sensitivity is 71% and
and online but is beyond the scope of this handout.11,12 their specificity is 80%.16
Tympanometry is no better than pneumatic otoscopy

Antibiotics for acute otitis media?

B ack in the 1980s, when I was a resident, I was

taught that any child with an earache has an acute
amoxicillin deficiency until proven otherwise. In the
immediate antibiotic decreases crying during the day
and provides better sleep the first day. It decreases pain,
but only slightly, and only on the second day of antibiot-
USA, parents bringing an infant or child to you with an ics, when symptoms are already improving. This small
earache usually expect antibiotics. In Europe, though, benefit may not outweigh complications such as diarrhea
they seldom get antibiotics.17,18 In the USA 95% of kids and creating resistant bacteria.29
with acute otitis media get antibiotics; in the Nether-
Its now OK to give a safety-net antibiotic prescrip-
lands, its only 31-56%.19-21
tion,30 and tell parents not to fill it unless the ear pain
Having acute otitis media before youre 6 months old goes on for a couple of days. A lot of the time, parents
means youre more likely to get recurrent acute otitis dont fill the prescription. Parents are happy and youre
media later in life. But family history of allergy, breast- creating fewer resistant bugs.30,31 Telling the parents to
feeding, day care, gender, and home environment make call back for a prescription in a couple of days has the
no difference in how likely you are to get acute otitis same satisfaction rate, but seems to me as though it
media.22 Recurrent acute otitis media tends to resolve as would work better for offices than EDs.32,33 Nobody has
children grow older.23 There is some evidence that, for (yet) studied delayed antibiotics for adults.
children with recurrent episodes of acute otitis media,
The American Academy of Pediatrics and American
that prophylactic antibiotics, either throughout the
Academy of Family Physicians 2013 joint clinical practice
cold season, or with onset of a viral upper respiratory
guideline5 says:
infection, may help prevent acute otitis media.24 But the
2013 AAP-AAFP guidelines5 state: Clinicians should not The clinician should prescribe antibiotic therapy for
prescribe prophylactic antibiotics to reduce the frequency AOM (bilateral or unilateral) in children 6 months
of episodes of AOM in children and older with severe signs or symptoms (i.e., mod-
with recurrent AOM. erate or severe otalgia or otalgia for at least 48 hours
or temperature 39C [102.2F] or higher).
I was taught to prescribe anti-
The clinician should prescribe antibiotic therapy
biotics for acute otitis media
for bilateral AOM in children 6 months through 23
to decrease the incidence of
months of age without severe signs or symptoms (i.e.,
deafness. However, permanent
mild otalgia for less than 48 hours and temperature
deafness comes primarily
less than 39C [102.2F]).
from chronic otitis media (2
or more weeks of otitis media The clinician should either prescribe antibiotic
with discharge) which is quite therapy or offer observation with close follow-up
rare in North America; 25 acute based on joint decision making with the parent(s)/
otitis media does not cause caregiver for unilateral AOM in children 6 months to
permanent deafness, but its 23 months of age without severe signs or symptoms
common to have a bit of tem- (i.e., mild otalgia for less than 48 hours and tem-
porary deafness from left-over perature less than 39C [102.2F]). When observa-
fluid in the middle ear.26 Worse tion is used, a mechanism must be in place to ensure
complications, such as perma- follow-up and begin antibiotic therapy if the child
nent deafness or death from worsens or fails to improve within 48 to 72 hours of
brain infection, are rare outside the developing world.27 onset of symptoms.
The clinician should either prescribe antibiotic
If we prescribe lots of antibiotics for red tympanic mem-
therapy or offer observation with close follow-up
branes, do we create resistant bacteria? Yes. Do we help
based on joint decision-making with the parent(s)/
2 or hurt the patient? We may be hurting the patient.28 An
 caregiver for AOM (bilateral or unilateral) in BID or TID; maximum 30 mg/kg/day if child is < 3
children 24 months or older without severe signs or months old) you prescribe high-dose (80-90 mg/kg/day
symptoms (ie, mild otalgia for less than 48 hours divided BID, though a conservative Cochran Review
and temperature less than 39C [102.2F]). When says to give TID35), for a full 7-10 days.36 A single shot of
observation is used, a mechanism must be in place IM ceftriaxone, or 5 days of oral azithromycin, are good
to ensure follow-up and begin antibiotic therapy if alternatives.37
the child worsens or fails to improve within 48 to 72
The 2013 AAP-AAFP guidelines succinctly but confus-
hours of onset of symptoms.
ingly states: Clinicians should prescribe amoxicillin for
This may be summarized as: Treat with antibiotics if acute otitis media when a decision to treat with
severe acute otitis media, or if nonsevere bilateral acute antibiotics has been made and the child has
otitis media in young children. Treat with antibiotics or not received amoxicillin in the past 30 days or
observe (no antibiotics and have patient call back if not the child does not have concurrent purulent
improving, or provide a safety net prescription) if non- conjunctivitis or the child is not allergic to
severe unilateral acute otitis media in young children, or penicillin. When Im not playing doctor I play
if nonsevere acute otitis media in older children. computer nerd and think in Boolean logic, so
I would reword it thusly: prescribe amoxicil-
But there is a review of antibiotics for acute otitis media
lin unless ((the child has had amoxicillin in
in children from the Cochrane Collaboration.34 Un- Normal Tympanic Membrane
the past 30 days) OR (the child has otitis- (Wikimedia Commons)
like the US-only AAP-AAFP guideline, it represents
conjunctivitis syndrome) OR (the child is
worldwide experts. It notes that antibiotics decrease
allergic to penicillins)).
pain only slightly and only for a couple of days, and, they
dont decrease temporary deafness, rupture of the TM, If, after three days of an antibiotic, the patient still has,
or mastoiditis. And, 37% of those who get antibiotics get fever, ear pain, a red, bulging TM, or discharge from the
vomiting, diarrhea or rash. So, the Cochrane Review says ear, what do you do? High-dose amoxicillinclavulanate
that you should prescribe antibiotics only if: (AUGMENTIN), or cefuroxime axetil (CEFTIN), or
there is bilateral acute otitis media, or intramuscular ceftriaxone (ROCEPHIN) for three days.38
And if you see a patient with this in the ED, emphasize
there is acute otitis media with otorrhea (dis-
the need for primary-care follow-up!
charge from the ear).
Repeat episodes of acute otitis media (more than a
So what do you do? I treat acute otitis media only if Im
month after the first time) is almost always (>90%) from
absolutely sure its there and it looks bad, otherwise I
a new virus or bacterium.39 Amoxicillin-clavulanate
just treat for eustachian tube dysfunction, with oxy-
(AUGMENTIN) is probably appropriate at this point.
metazoline (AFRIN) nasal spray, as described below.
BTW, when a mother (it always seems to be the mother,
Bacteria that cause acute otitis media are often resistant
not the father) says amoxicillin never works for his/
to amoxicillin (particularly pneumococcus: Streptococ-
her ear infections! I believe the mother. Some kids are
cus pneumoniae). But amoxicillin is still the first-line
probably colonized with highly amoxicillin-resistant
antibiotic; its as good as other antibiotics, because the
bacteria. Our scientific studies are not good enough yet
amoxicillin concentrates in middle ear fluid, enough
to tease out these outliers. So I prescribe something else,
to overcome the resistance.38,39 That is, if, instead of
and call it the art of medicine.
standard-dose amoxicillin (25-50 mg/kg/day divided

Other Treatments for acute otitis media

O ral decongestants and antihistamines might

help just slightly, but cause so many problems that
the cure is worse than the disease.40,41 And taking them
I describe as being addicted to nasal spray so you have
to use it to breathe through your nose.43,44 I tell them to
spray into both nostrils, then lie flat on their backs for a
during a cold doesnt prevent acute otitis media.42 few minutes, so that they can taste the spray getting back
to where the Eustachian tubes drain out in the back of
A decongestant nasal spray such as oxymetazoline (AF-
the nose/throat.
RIN) helps a bit: ~19% residual effusion at one month as
opposed to 27% residual effusion for oral decongestants, Antipyrine and benzocaine ear drops (commonly known
antihistamines, or untreated controls.41 I recommend a as AURALGAN, though no longer available under that
few days of oxymetazoline (AFRIN) nasal spray less brand name) may help the pain a bit.45,46
than 10 days to avoid rhinitis medicamentosa, which

Otitis-Conjunctivitis Syndrome

C onjunctivitis and otitis media are sometimes

occur together, and the combination is highly likely
to be caused by H influenzae;47 H. flu tends to be resistant
junctivitis, take a look at the ears; roughly 2/3 will also
have otitis media.53 Treat with an oral antibiotic, but you
dont need to prescribe eye drops. The tears have enough
to amoxicillin and azithromycin (ZITHROMAX). So, of the oral antibiotic to work as antibiotic eye drops.54
when treating otitis media, look for conjunctivitis; if you
see it, consider amoxicillin-clavulanate (AUGMENTIN),
cefuroxime (CEFTIN) or cefdinir (OMNICEF).48-52
For the same reason, if you see a child with purulent con- 3
 Otitis Media with Effusion (OME; Glue Ear; Serous Otitis; Middle Ear Effusion)

S ometimes people come to the ED with decreased

hearing, sometimes sudden-onset. The most com-
mon cause is earwax impaction. But if you look in the
If you see a cloudy tympanic membrane, or a visible
effusion with an air-fluid level, or bubbles behind the
tympanic membrane, without symptoms of acute infec-
ear, and rather than a cerumen impaction, you might see tion, youve diagnosed serous otitis. Refer the patient to
a clear effusion fluid behind the tympanic membrane. a primary care doctor for follow-up. Its optional in the
Or, you might find the same on a routine ear exam. ED, but decreased mobility with insufflation confirms
your diagnosis.61
Middle ear effusions are common after acute otitis
media. Two weeks after they have otitis media, about Unfortunately, there is almost nothing we can do.
of kids will have a persistent effusion; a month after, half Antibiotics, antihistamines, oral decongestants, oral ste-
will; and three months later, maybe will. Antibiotics roids, mucolytics like guaifenesin (e.g., ROBITUSSIN,
dont help.3,55,56 MUCINEX) and autoinflation with a Politzer device
(dont ask) are all useless.7,62-66 Some think that many
Serous otitis may also come from eustachian tube
cases of adult serous otitis are from allergies.67 Espe-
dysfunction (ETD) from other causes: chronic eusta-
cially in adults with obvious nasal allergies, a nonsedat-
chian tube deformity, allergies,57 tobacco smoking and
ing antihistamine and a steroid nasal spray might help.
esophageal reflux.58 Less common causes include chronic
Since it may help acute otitis media,41 a short course of
sinus disease (particularly of the ethmoids), adenoidal
oxymetazoline (AFRIN) nasal spray less than 10 days
hyperplasia, and rarely head and neck tumors.59 People
to avoid rhinitis medicamentosa might help, too.43,44 As
with serous otitis may complain of a feeling of water in
with acute otitis media, I recommend a few minute lying
the ear, mild pain or decreased hearing. Serous otitis is
supine after spraying the nose. Refer to an appropri-
defined as fluid in the middle ear without signs or symp-
ate primary care physician. However, warn the patient
toms of ear infection. Like otitis media, its more com-
that treatment for kids with serous otitis is a three (3)
mon in kids.7 Serous otitis is not a big deal in the ED,
month period of watchful waiting, checking hearing
but its a big deal for pediatricians and family doctors, as
tests, and considering tympanostomy tubes.7
decreased hearing causes problems in class.60

Acute otitis media With Tubes or Ruptured TM

T ympanostomy tubes (myringotomy tubes, venti-

lation tubes, grommets) are sometimes surgically
inserted in the tympanic membranes of children with
when the tympanic membrane ruptures. Ninety-four
percent of the perforations were spontaneously healed
within a month. Children who have had a perforation are
recurrent acute otitis media or, particularly in children twice as likely to have recurrent acute otitis media.71
> 3 years old, chronic otitis media with effusion (serous
The bacteria in ear drainage in those under age 3 is the
otitis). The tubes are expected to drain fluid for days or
same as that in acute otitis media: a mixture of viruses
weeks after insertion. About 5% of children with tubes
and airway-derived bacteria.72,73 In older children, it will
develop chronic otorrhea (drainage from the ear), usu-
usually be skin flora including Pseudomonas aeruginosa
ally due to skin flora such as Pseudomonas aeruginosa and
and Staphylococcus aureus.74
Staphylococcus aureus.68
There are many treatments for such ear drainage, from
You may be unsure if a patient has a hole in the tympanic
doing nothing (observation), through ear drops, to
membrane or not. A patient may have had tympanos-
oral antibiotics. In children younger than 3 years old
tomy tubes in the past, and you cant tell if they are still
with acute tube-associated drainage, ear drops are as
there. And, sometimes, the pressure from acute otitis
good as oral antibiotics; ofloxacin ear drops (FLOXIN)
media will cause the tympanic membrane to rupture;
are as good as oral amoxicillin-clavulanate (AUGMEN-
this may fill the ear canal enough that its hard to tell if
TIN).75 Given that ear drops are effective for tube-associ-
youre dealing with otitis media with perforation or otitis
ated and perforation-associated ear drainage in all ages,
externa.
it seems prudent to use ear drops as the initial treatment,
Two clues to a perforated tympanic membrane are (1) unless there is severe ear pain or high fever, in which
people who can taste the drops after putting ear drops in case you should probably prescribe both ear drops (to
their ear, and (2) people who can blow air out their ear cover skin bacteria) and one of the usual otitis media oral
when blowing their noses.69 antibiotics.72,76
You may see an infant or child with known tympanos- Prescribe only non-ototoxic eardrops when there might
tomy tubes complaining of acute (sudden onset, severe) be a tube or perforation, as some of the ear drops may
otorrhea. This occurs in roughly half of children with get into the middle ear.77 Neomycin and polymyxin B
tubes.70 From the drainage, the external ear canal may and hydrocortisone otic suspension (CORTISPORIN)
look eczematous.69 The patient may have a low-grade contains both an ototoxic aminoglycoside (neomycin) as
temperature or fatigue, but due to the tubes, not much well as ototoxic propylene glycol; acetic acid ear drops
pain. (VOSOL, ACETASOL; VOSOL-HC, ACETASOL-HC)
also contain ototoxic propylene glycol, as well as being
About a third of kids with acute otitis media have a spon-
acidic enough to make the middle ear hurt, so dont
taneous rupture of the tympanic membrane during one
prescribe them if there might be a tube or perforation,
of their episodes of otitis media, more likely if theyve
unless the benefits outweigh the risks. 77,78 Oflaxacin
had prior otitis media. Usually the pain gets a lot better
4 (FLOXIN) and ciprofloxacin/dexamethasone (CIPRO-
DEX) drops are non-ototoxic.78 Including a steroid with ing with appropriate antibiotics, culture the drainage,
an antibiotic may make ear drops slightly more effective, but dont change treatment. Refer for primary care
but generic ofloxacin (FLOXIN) drops are both cheap physician follow-up and the physician may use culture
and effective.79,80 results to guide treatment. If there is new ear pain or
fever, and the patient is on just ear drops, start oral
If you see a child with tubes with discharge not improv-
antibiotics.72

Mastoiditis and Petrositis

I n the early 1900s, a fifth of those with acute

otitis media got mastoiditis or petrositis. But since
antibiotics became available in the 1930s, they became
further workup and treatment. Myringotomy is usu-
ally performed and tympanostomy tubes are generally
placed. If there is neither subperiosteal abscess nor CNS
rare (<1%), especially in the US and other developed involvement, a period of 48 hours of observation and
nations.81 broad-spectrum IV antibiotics is recommended prior to
considering mastoidectomy.93 Subperiosteal abscesses
Mastoiditis is a symptomatic infection of the air cells in are surgically drained.
the bony mastoid process behind the ear, most com-
monly in infants.82 Classic mastoiditis shows swelling The triad of deep facial pain, otitis media, and ipsilat-
and perhaps warmth or redness over the mastoid, with eral abducens nerve paralysis (inability to look to the
the pinna (auricle) pushed down and forwards. But affected side) are the classic signs of petrositis (infection
soon after the first use of antibiotics for otitis media, of the petrous portion of the temporal bone; Gradenigos
in 1941, there were reports of masked mastoiditis: Syndrome)94 However, as with mastoiditis, such classic
patients with further complications of mastoiditis, such presentations are now rare.
as brain abscess, without classic signs and symptoms.83,84 If you see someone who Key Points
Now, the most common findings are only seen with an presents with deep facial Chronic suppurative otitis a couple of days.
otoscope: an abnormal appearing tympanic membrane, pain and signs or symptoms media, which causes serious High-dose amoxicillin, due
long-term problems, occurs to high concentrations in the
and sagging of the posterior wall of the external ear of infection, and a history almost entirely in the devel- middle ear that will kill even
canal.2 Although the ear may not be visible displace, but of chronic otitis media or oping world. resistant organisms, is still the
sometimes the postauricular fold the crease behind the surgery for mastoiditis, you You should diagnose acute drug of choice for acute otitis
pinna (auricle) of the ear is gone; compare with the should suspect petrositis.95 otitis media by: media.
unaffected side.85 Get a CT or MRI scan, signs and symptoms of acute Although nasal-spray decon-
otitis media (fever, earache); gestants may help acute otitis
and consider admitting the and media, oral decongestant and
Trying to confirm a clinical suspicion of mastoiditis is patient for further workup antihistamines are not recom-
evidence of a middle ear
hard, as there are no accepted diagnostic criteria.86 And, and treatment. A CT scan effusion. mended (dont help much or
as with fluid in the sinuses on CT that occurs with most showing bony changes
at all, lots of side effects).
You should diagnose a middle
any cold,87-89 fluid in the mastoid air cells on CT scan in the petrous part of the ear effusion when you see: Otitis-Conjunctivitis Syn-
drome is usually from H influ-
doesnt diagnose mastoiditis, as its found in many cases temporal bone clinches the fluid behind the tympanic enzae; prescribe Augmentin
of otitis media.90 If you do a high-resolution CT or MRI diagnosis.95 Mastoidectomy
membrane, or rather than amoxicillin.
and find bony resorption in the mastoid (the bony septae is a common inpatient
decreased mobility with For otitis media with effusion
between the mastoid air cells are being destroyed) then insufflation , or (serous otitis), no acute treat-
treatment, but conserva- opacity or discoloration of ments work, except maybe
you can diagnose coalescent mastoiditis, but CT or tive management with just decongestant nasal spray, or if
tympanic membrane (not
MRI wont help you diagnose earlier stages of mastoid- antibiotics is reasonable as counting scarring), or allergic, steroid nasal spray. It
itis.86,91,92 well. 96-98 evidence from tympanom-
is simply observed for months
for resolution.
etry or spectral gradient
Patients with mastoiditis are generally admitted for acoustic reflectometry. For acute otitis media with
tympanostomy tubes or a rup-
Do not diagnose acute otitis
tured tympanic membrane,
media when you just see
treat not with oral antibiotics,
Bullous Myringitis redness of the tympanic
but with non-ototoxic ear

I
membrane.
drops such as ofloxacin or
was taught that bullous myringitis tiny blisters myringitis hurts worse than Should you treat acute ciprofloxacin.
otitis media with antibiotics?
on the tympanic membrane clinches the diagnosis other types of acute otitis Maybe. There are dueling
Mastoiditis and petrositis
media.100 As one review (Gradenigos Syndrome) are
mycoplasma-induced otitis media.99 But the bacteria recommendations.
quite rare in the developed
in ears with bullous myringitis are basically the same put it, bullous myringitis is You can, for certain kids with world, and while CT or MRI
as in any case of acute otitis media,100 though bullous just acute otitis media with acute otitis media, give a may help a bit, you have to
prescription for an antibiotic make the initial diagnosis
blisters on the eardrum.99 but tell the parents not to fill it clinically.
unless the ear is still hurting in

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