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I.

History
A. General Data
J.G., 35 years old, Female, married, Roman Catholic, presently residing at Pasay City came in
our institution for OPD consult for the first time.
B. Chief Complaint: Ear pain, left
C. History of Present Pregnancy
Four days PTC, patient noted to have left ear pain, 5/10 pain scale, after an ear manipulation.
This was associated left ear discharge non-foul smelling and clear in character, tinnitus, colds and
cough. No medication taken and no consult done.
On the day of consult, persistence of symptoms prompted patient to sought consult.
D. Past Medical History
2003 Goiter, unrecalled medication but currently non-compliant to any medication.
She is non-hypertensive, non-diabetic and no history of pulmonary tuberculosis, asthma,
cancer, cardiovascular disease and kidney disease. She had no previous history of surgery and
hospitalizations. She had no history of allergy to any medications or any food.
E. Family History
There is a history of hypertension on paternal side and diabetes mellitus on the maternal side.
There were no history of asthma, cardiovascular disease, malignancies and kidney disease in her
family.
F. Obstetrical History: Gravida 2 Para 2 (2002)
G. Menstrual and Gynecological History
The patient had her menarche at the age of 11 occurring at regular intervals of 28 days lasting
for 3-4 days consuming 3 moderately soaked napkins per day and not associated with dysmenorrhea.
No pap smear done and no history of contraceptive use.
H. Sexual History
Patient had her first contact at the age 20 years old and had 3 sexual partners. She denies any
history of dyspareunia, postcoital bleeding, leukorrhea and exposure to sexually transmitted infection.
I. Personal and Social History
Patient is non-smoker, non-alcohol beverage drinker and denies illicit drug use. She is a high
school undergraduate and work as a maid. She lives at her boss house with their 5 children. Garbage is
collected every day and drinking water is distilled.
II. Review of Systems
General: (-) chills night sweats, fever, change in weight
Skin: (-) scars, lesions, rashes, ulcerations, excoriations
HEENT:
Head: (-) Headache, masses, bruises
Eyes: (-) eye pain, red eyes, eye itchiness, eye discharge
Nose: (-) colds, nasal discharge, epistaxis, trauma
Neck: (+) goiter, (-) neck pain, cervical lymphadenopathy
Throat: (-) throat pain, dysphagia
Respiratory: (-) difficulty of breathing dyspnea, hemoptysis, cough, colds
Heart: (-) cyanosis, edema, heart murmurs, chest pain, palpitations
Gastrointestinal: (-) nausea and vomiting, loss of appetite, abdominal pain, diarrhea, jaundice
Genitourinary: (-) dysuria, frequency, urgency, nocturia, enuresis, hematuria, vaginal discharge and
itchiness
Extremities: (-) swelling bilateral extremities , warmth/erythema, joint pain, muscle pain, cramps
Neurologic/Psychiatric: (-) mental status changes, agitation, disorientation, mood change, weakness

III. Physical Examination

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A. General Survey: In general, the patient looks healthy, small-framed woman, dressed and groomed
appropriated for her age. She is alert, awake, and responsive to the examiner. She is sitting on the chair,
ambulatory, not in respiratory distress and pain.
B. Vital Signs and Anthropometrics
Result
Weight = 59 kg
BMI = 23.7 kg/m2 (normal)
Height = 152 cm
BP = 130/80 mmHg Normotensive
PR = 81 bpm, regular rhythm Normal
RR = 16 breath/min Normal
Temperature = 36.9 Celsius (axillary) Afebrile

C. Skin and Appendages: The patients skin is fair, warm to touch and she has good skin turgor. No
raches, no edema, erythema, cyanosis, pallor, masses or lesions noted. The nail beds were not pale and
no clubbing or koilonychias were observed.
D. HEENT:
The patient has medium length, black hair with evenly distributed volume, pattern and
texture. Her head is symmetrical and normocephalic without lesions, masses, scars and tenderness. The
scalp has no lesions, non-edematous, no parasites nor scales.
Upon inspection, her eyes are symmetrical and not protruding. There were no ptosis or
strabismus noted. The eyebrows are also symmetrical and with equal hair distribution, eyelids were
non-edematous. Lacrimal glands were not swollen or tender. She has pink palpebral conjunctiva with
no inflammation, masses nor ulcerations noted. She has anicteric sclera with no corneal ulcers or
opacities. Her pupils are equally reactive to light, accommodation, consensual reflex. No visible
lesions, masses, ulcerations or serous drainage in the ears.
Her auricles were symmetrical. Tympanic membrane on left ear was not seen due to
retained cerumen, clear and non-foul smelling discharge was seen while tympanic membrane on
right is intact with no cerumen seen. There was left ear tragal tenderness noted.

Her nose is symmetrical and nasal septum is in midline. External nares are equal in size
and shape. Vestibule and nasal cavity has no masses, no serous/purulent/blood-tinged drainage. Both
nostrils are patent without watery/mucoid discharge. No nasal flaring was noted.
The lips are symmetrical, no masses or ulcerations. Gums and buccal areas are pinkish
free of lesions, masses or ulcerations. The tongue is pinkish and mobile, free of masses or ulcerations.
The palate is smooth and free of lesions. The floor of mouth is free of masses or ulcers. No
pharyngotonsilar congestion noted.
Anterior neck mass on the left, soft, non-movable, moves with deglutition and
approximately 3 cm x 2 cm x 3 cm in size was noted. Neck has no limitation of motion and any
nuchal spasm or rigidity. There was no lymphadenopathy, no enlargement of parotid and
submandibular glands and cervical lymph nodes noted. Thyroid gland moves with swallowing and
trachea is in midline position.

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(+) left anterior neck mass, soft, non-tender, moves with
deglutition, approximately 3cmx2cmx2cm in dimension,
E. Chest and Lungs: Upon inspection, chest is symmetrical; no chest retractions and use of accessory
muscles; no masses, lesions, discolorations or deformities; symmetrical chest expansion. On palpation,
there was no cervical lymphadenopathy. Resonant on all lung fields, no dullness and chest lag noted.
Upon auscultation, vesicular on all lung fields and clear breath sounds. No wheezes, crackles, rales and
rhonchi noted.
F. Cardiovascular System: On inspection, no precordial bulging noted. PMI is at 4th ICS LMCL. Upon
palpation, no thrills and no heaves noted. Apex beat at 4th ICS LMCL. Patient had normal rate and
rhythm with no murmurs. At apex, S2>S1 while at the base S1>S2.
G. Breast: Breasts are symmetrical and non-tender.
H. Abdomen: Upon inspection, abdomen is flabby with inverted umbilicus. No engorged or dilated veins,
visible pulsations noted. On auscultation, normoactive bowel sound, no boborygmi noted. There was
no tenderness on light and deep palpation in all quadrants.
I. Extremities: (-) for clubbing, cyanosis, venous engorgement, hemorrhages, contusion; (+) strong
central and peripheral pulses; (+) rapid capillary refill, (-) bipedal edema
IV. Diagnosis: Acute Otitis Media, Stage III, AS

V. Plan and Management


Diet as tolerated and increase oral fluid intake
Teach Aural Toilette
Medications:
1) Ciprofloxacin + Dexamethasone, 2-3 drops TID for 7 days
2) Amoxicillin + Clavulanic Acid (Amoxiclav) 625 mg/tab, TID for 7 days
3) Phenylpropanolamine 500mg/tab, TID for days
4) Celecoxib 200mg/capsule, BID, prn for pain
Advised for referral to an Endocrinologist for management of goiter
For thyroid laboratory work-up
1) TSH, T3 and T4 serum level
2) Thyroid gland ultrasound
For follow-up check-up after 1 week with laboratory results

VI. Discussion: Acute Otitis Media

Anatomy1
The ear consists of three parts: the outer ear, middle ear and inner ear. The ear canal of the outer
ear is separated from the air-filled tympanic cavity of the middle ear by the eardrum. The middle ear contains the

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three small bones called ossicles which involved in the transmission of sound, and is connected to the throat at the
nasopharynx, via the pharyngeal opening of the Eustachian tube. The inner ear contains the otolith organs, utricle
and saccule, and the semicircular canals belonging to the vestibular system, as well as the cochlea of the auditory
system.

The Outer Ear


The outer ear is the external portion of the ear and
includes the fleshy visible pinna (also called the Auricle), the ear canal,
and the outer layer of the eardrum (also called the Tympanic
Membrane). The pinna consists of the curving outer rim called the
helix, the inner curved rim called the antihelix, and opens into the ear
canal. The tragus protrudes and partially obscures the ear canal, as does
the facing antitragus. The hollow region in front of the ear canal is
called the concha. The ear canal stretches for about 1 inch (2.5 cm). The
first part of the canal is surrounded by cartilage, while the second part near the eardrum is surrounded by bone. This
bony part is known as the auditory bulla and is formed by the tympanic part of the temporal bone. The skin
surrounding the ear canal contains ceruminous and sebaceous glands that produce protective ear wax. The ear canal
ends at the external surface of the eardrum. Two sets of muscles are associated with the outer ear: the intrinsic and
extrinsic muscles. The ear muscles are supplied by the facial nerve, which also supplies sensation to the skin of the
ear itself, as well as to the external ear cavity. The great auricular nerve, auricular nerve, auriculotemporal nerve, and
lesser and greater occipital nerves of the cervical plexus all supply sensation to parts of the outer ear and the
surrounding skin. The pinna consists of a single piece of elastic cartilage with a complicated relief on its inner
surface and a fairly smooth configuration on its posterior surface. The symmetrical arrangement of the two ears
allows for the localization of sound. The brain accomplishes this by comparing arrival-times and intensities from
each ear, in circuits located in the superior olivary complex and the trapezoid bodies which are connected via
pathways to both ears.

The Middle Ear


The middle ear lies between the outer ear and the inner ear. It consists of an air-filled cavity called
the tympanic cavity and includes the three ossicles and their attaching ligaments; the auditory tube; and the round
and oval windows. The ossicles are three small bones that function together to receive, amplify, and transmit the
sound from the eardrum to the inner ear. The ossicles are the malleus (hammer), incus (anvil), and the stapes
(stirrup). The stapes is the smallest named bone in the body. The middle ear also connects to the upper throat at the
nasopharynx via the pharyngeal opening of the Eustachian tube. The three ossicles transmit sound from the outer
ear to the inner ear. The malleus receives vibrations from sound pressure on the eardrum, where it is connected at its
longest part (the manubrium or handle) by a ligament. It transmits vibrations to the incus, which in turn transmits the
vibrations to the small stapes bone. The wide base of the stapes rests on the oval window. As the stapes vibrates,

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vibrations are transmitted through the oval window, causing movement of fluid within the cochlea. The round
window allows for the fluid within the inner ear to move. As the stapes pushes the secondary tympanic membrane,
fluid in the inner ear moves and pushes the membrane of the round window out by a corresponding amount into the
middle ear. The ossicles help amplify sound waves by nearly 1520 times.

The Inner Ear


The inner ear sits within the temporal bone in a complex cavity called the bony labyrinth. A
central area known as the vestibule contains two small fluid-filled recesses, the utricle and saccule. These connect to
the semicircular canals and the cochlea. There are three semicircular canals angled at right angles to each other
which are responsible for dynamic balance. The cochlea is a spiral shell-shaped organ responsible for the sense of
hearing. These structures together create the membranous labyrinth. The bony labyrinth refers to the bony

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compartment which contains the membranous labyrinth, contained within the temporal bone. The inner ear
structurally begins at the oval window, which receives vibrations from the incus of the middle ear. Vibrations are
transmitted into the inner ear into a fluid called endolymph, which fills the membranous labyrinth. The endolymph is
situated in two vestibules, the utricle and saccule, and eventually transmits to the cochlea, a spiral-shaped structure.
The cochlea consists of three fluid-filled spaces: the vestibular duct, the cochlear duct, and the tympanic duct. Hair
cells responsible for transduction changing mechanical changes into electrical stimuli are present in the organ of
Corti in the cochlea.

Blood supply
The blood supply of the ear differs according to each part of the ear. The outer ear is supplied by a
number of arteries. The posterior auricular artery provides the majority of the blood supply. The anterior auricular
arteries provide some supply to the outer rim of the ear and scalp behind it. The posterior auricular artery is a
direct branch of the external carotid artery, and the anterior auricular arteries are branches from the superficial
temporal artery. The occipital artery also plays a role. The middle ear is supplied by the mastoid branch of either the
occipital or posterior auricular arteries or the deep auricular artery, a branch of the maxillary artery. Other
arteries which are present but play a smaller role include branches of the middle meningeal artery, ascending
pharyngeal artery, internal carotid artery, and the artery of the pterygoid canal. The inner ear is supplied by the
anterior tympanic branch of the maxillary artery; the stylomastoid branch of the posterior auricular artery; the
petrosal branch of middle meningeal artery; and the labyrinthine artery, arising from either the anterior inferior
cerebellar artery or the basilar artery.

Acute Otitis Media3


In the United States, acute otitis media (AOM), defined by convention as the first 3 weeks of a
process in which the middle ear shows the signs and symptoms of acute inflammation, is the most common
affliction necessitating medical therapy for children younger than 5 years.

Epidemiology
In the United States, 70% of all children experience one or more attacks of AOM before their
second birthday. A study from Pittsburgh that prospectively followed urban and rural children for the first 2 years of
life determined that the incidence of middle ear effusion episodes is approximately 48% at age 6 months, 79% at age
1 year, and 91% at age 2 years. The peak incidence of AOM is in children aged 3-18 months. Some infants may
experience their first attack shortly after birth and are considered otitis-prone (i.e., at risk for recurrent otitis media).
In the Pittsburgh study, the incidence was highest among poor urban children. Differences in incidence between
nations are influenced by racial, socioeconomic, and climatic factors. Children aged 6-11 months appear particularly
susceptible to AOM, with frequency declining around age 18-20 months. The incidence is slightly higher in boys
than in girls. A small percentage of children develop this disease later in life, often in the fourth and early fifth year.
After the eruption of permanent teeth, incidence drops dramatically, although some otitis-prone individuals continue
to have acute episodes into adulthood. Occasionally, an adult with an acute viral URTI but no previous history of ear

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disease presents with AOM. Definite racial differences exist in the incidence of AOM. Native Americans and Inuits
have very high rates of acute and chronic ear infection, whereas African Americans appear to have a slightly lower
rate than white children living in the same communities. The history of acute otitis media (AOM) varies with age,
but a number of constant features manifest during the otitis-prone years.

Pathophysiology
Obstruction of the Eustachian tube appears to be the most important antecedent event associated
with AOM. The vast majority of AOM episodes are triggered by an upper respiratory tract infection (URTI)
involving the nasopharynx.
The infection is usually of viral origin, but allergic and other inflammatory conditions involving
the Eustachian tube may create a similar outcome. Inflammation in the nasopharynx extends to the medial end of the
Eustachian tube, creating stasis and inflammation, which, in turn, alter the pressure within the middle ear. These
changes may be either negative (most common) or positive, relative to ambient pressure. Stasis also permits
pathogenic bacteria to colonize the normally sterile middle ear space through direct extension from the nasopharynx
by reflux, aspiration, or active insufflation. The response is the establishment of an acute inflammatory reaction
characterized by typical vasodilatation, exudation, leukocyte invasion, phagocytosis, and local immunologic
responses within the middle ear cleft, which yields the clinical pattern of AOM. In a minority of otitis-prone
children, the Eustachian tube is patulous or hypotonic. Children with neuromuscular disorders or abnormalities of
the first or second arch are most likely too open and are therefore predisposed to reflux of nasopharyngeal
contents into the middle ear cleft. To become pathogenic in hollow organs, such as the ear or sinus, most bacteria
must adhere to the mucosal lining. Viral infections that attack and damage mucosal linings of respiratory tracts may
facilitate the ability of the bacteria to become pathogenic in the nasopharynx, Eustachian tube, and middle ear cleft.

Risk factors
The following are proven risk factors for otitis media:
Prematurity and low birth weight
Young age
Early onset
Family history
Race - Native American, Inuit, Australian aborigine
Altered immunity
Craniofacial abnormalities
Neuromuscular disease
Allergy
Day care
Crowded living conditions
Low socioeconomic status
Tobacco and pollutant exposure
Use of pacifier
Prone sleeping position
Fall or winter season
Absence of breastfeeding, prolonged bottle use

Signs and symptoms

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Although the history of AOM varies with age, a number of constant features manifest during the
otitis-prone years, including the following:
Neonates: Irritability or feeding difficulties may be the only indication of a septic focus
Older children: This age group begins to demonstrate a consistent presence of fever and otalgia, or ear tugging
Older children and adults: Hearing loss becomes a constant feature of AOM and otitis media with effusion
(OME); ear stuffiness is noted before the detection of middle ear fluid
Otalgia without hearing loss or fever is observed in adults with external otitis media, dental
abscess, or pain referred from the temporomandibular joint. Orthodontic appliances often elicit referred pain as the
dental occlusion is altered.

Staging
The disease runs through the following stages:
1. Stage of tubal occlusion
2. Stage of pre-suppuration
3. Stage of suppuration
4. Stage of resolution or complication
1. Stage of tubal occlusion
Edema and hyperemia of nasopharyngeal end of Eustachian tube blocks the tube, leading to
absorption of air and negative intratympanic pressure. There is retraction of tympanic membrane with some
degree of effusion in the middle ear but fluid may not be clinically appreciable. Deafness and earache are the
two symptoms but they are not marked. There is generally no fever. Tympanic membrane is retracted with
handle of malleus assuming a more horizontal position, prominence of lateral process of malleus and loss of
light reflex; and there is also conductive deafness.
2. Stage of pre-suppuration
If tubal occlusion is prolonged, pyogenic organisms invade tympanic cavity causing hyperemia of
its lining. Inflammatory exudate appears in the middle ear. Tympanic membrane becomes congested. There is
marked earache which my disturb sleep and is of throbbing nature. Deafness and tinnitus are present, but
complained only by adults.
Usually, child runs high degree of fever and is restless. To begin with, there is congestion of pars
tensa. Leash of blood vessels appear along the handle of malleus and at the periphery of tympanic membrane
imparting a cart-wheel appearance. Later, whole of tympanic membrane including pars flaccida becomes
uniformly red. There is a conductive type of hearing loss.
3. Stage of suppuration
This is marked by formation of pus in the middle ear and to some extent in mastoid air cells.
Tympanic membrane starts bulging to the point of rupture. Earache becomes excruciating. There is deafness and
fever of 102-103F. This may be accompanied by vomiting and even convulsions. Tympanic membrane appears
red and bulging with loss of landmarks. Handle of malleus may be engulfed by the swollen and protruding
tympanic membrane and may not he discernible. A yellow spot may be seen on the tympanic membrane where

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rupture is imminent. In pre-antibiotic era, one could see a nipple-like protrusion of tympanic membrane with a
yellow spot on its summit. Tenderness may elicit over the mastoid antrum. X-rays of mastoid will show
clouding of air cells because of exudate.
4. Stage of resolution
The tympanic membrane ruptures, with release of pus and subsidence of symptoms. Inflammatory
process begins to resolve. If proper treatment is started early or if the infection was mild, resolution may start
even without rupture of tympanic membrane. With evacuation of pus, earache is relieved temperature may be
normal. External auditory canal may contain blood tinged discharge which later becomes mucopurulent.
Usually, a small perforation is seen in antero-inferior quadrant of pars tensa. Hyperemia of tympanic membrane
begins to subside with return to normal color and landmarks.
5. Stage of complication
If virulence of organism is high or resistance of patient poor, resolution may not take place and
disease spreads beyond the confines of middle ear. It may lead to acute mastoiditis, subperiosteal abscess, facial
paralysis, labyrinth itis, petrositis, extradural abscess, meningitis, brain abscess or lateral sinus
thrombophlebitis.

Diagnosis
Pneumatic otoscopy is the standard of care in the diagnosis of acute and chronic otitis media. The
following findings may be found on examination in patients with AOM:
Signs of inflammation in the tympanic membrane
Bulging in the posterior quadrants of the tympanic membrane may bulge; scalded appearance of the superficial
epithelial layer
Perforated tympanic membrane (most frequently in posterior or inferior quadrants)
Presence of an opaque serum-like exudate oozing through the entire tympanic membrane
Pain with/without pulsation of the otorrhea
Fever

Diagnostic Studies and Imaging studies


Radiologic studies are generally unnecessary in uncomplicated AOM. However, CT scanning may
be necessary to determine if a complication has occurred. MRI might be more appropriate for diagnosing suspected
intracranial complications.

Tympanocentesis involves aspiration of the contents of the middle ear cleft by piercing the
tympanic membrane with a needle and collecting that material for diagnostic examination.
Tympanocentesis should be performed in the following patients with AOM:
Neonates who are younger than 6 weeks (and therefore are more likely to have an unusual or more invasive
pathogen)
Immunosuppressed or immunocompromised patients

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Patients in whom adequate antimicrobial treatment has failed and who continue to show signs of local or
systemic sepsis
Patients with a complication that requires a culture for adequate therapy

Management
1. Pharmacotherapy
Antibiotics are the only medications with demonstrated efficacy in the management of AOM;
therefore, these agents are the initial therapy of choice. The antibiotic chosen should cover most of the common
bacterial pathogens and be individualized for the child with regard to allergy, tolerance, previous exposure to
antibiotics, cost, and community resistance levels. Duration of treatment may also be a consideration in the
choice of antibiotic. Antibiotics used in the management of AOM include the following:
Amoxicillin
Amoxicillin/clavulanate
Erythromycin base/Sulfisoxazole
Trimethoprim-sulfamethoxazole
Cefixime
Cefuroxime axetil
Cefprozil
Cefpodoxime
Cefdinir
Clindamycin
Clarithromycin
Azithromycin
Ceftriaxone
Some order has been brought to the discussions of antibiotic use under the auspices of the Centers
for Disease Control and Prevention (CDC) and by the Agency for Health Care Policy and Research (AHCPR), both
agencies of the US government. The CDC published 6 principles of appropriate antibiotic use in an attempt to bring
precepts of good public health and responsible therapy to the discussion while minimizing the selection of resistant
strains of bacteria within the community. These principles are as follows:
Episodes of otitis media should be classified as AOM or otitis media with effusion (OME)
Antimicrobials are indicated for treatment of AOM; however, diagnosis requires documented middle ear
effusion and signs or symptoms of acute local or systemic illness
Uncomplicated AOM may be treated with a 5- to 7-day course of antimicrobials in certain patients older than 2
years
Antimicrobials are not indicated for the initial treatment of OME; treatment may be indicated if effusions persist
for longer than 3 months
Persistent OME after therapy for AOM is expected and does not require repeat treatment with antimicrobials
Antimicrobial prophylaxis should be reserved for controlling recurrent AOM, defined as 3 or more distinct,
well-documented episodes in 6 months or 4 or more episodes in 12 months
2. Surgery
Surgical management of AOM can be divided into the following 3 related procedures:
Tympanocentesis
Myringotomy

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Myringotomy with insertion of a ventilating tube
Selection of the appropriate procedure results from evaluation of patient factors, surgeon factors,
available resources, and urgency.

Complications
The complications of AOM are classified by location as the disease spreads beyond the mucosal
structures of the middle ear cleft. They may be categorized as follows:
a) Intratemporal - Perforation of the tympanic membrane, acute coalescent mastoiditis, facial nerve palsy,
acute labyrinthitis, petrositis, acute necrotic otitis, or development of chronic otitis media
b) Intracranial - Meningitis, encephalitis, brain abscess, otitis hydrocephalus, subarachnoid abscess, subdural
abscess, or sigmoid sinus thrombosis
c) Systemic - Bacteremia, septic arthritis, or bacterial endocarditis
Danger signs of possible impending complications include (1) sagging of the posterior canal wall,
(2) puckering of the attic, and (3) swelling of post-auricular areas with loss of the skin crease.

Prognosis
Death from AOM is rare in the era of modern medicine. With effective antibiotic therapy, the
systemic signs of fever and lethargy should begin to dissipate, along with the localized pain, within 48 hours.
Children with fewer than 3 episodes are 3 times more likely to resolve with a single course of antibiotics, as are
children who develop AOM in non-winter months. Typically, patients eventually recover the conductive hearing loss
associated with AOM. Middle ear effusion and conductive hearing loss can be expected to persist well beyond the
duration of therapy, with up to 70% of children expected to have middle ear effusion after 14 days, 50% at 1 month,
20% at 2 months, and 10% after 3 months, irrespective of therapy. In most instances, persistent middle ear effusion
can merely be observed without antimicrobial therapy; however, a second course of either the same antibiotic or a
drug of a different mechanism of action may be warranted to prevent a relapse before resolution.

Source:
1. https://en.wikipedia.org/wiki/Ear
2. Grays Anatomy 3rd Edition
3. Medscape: Otitis Media. http://emedicine.medscape.com

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