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Acute otitis media in children: Epidemiology, microbiology, clinical manifestations, and complications

Jerome O Klein, MD
Stephen Pelton, MD
Section Editors
Sheldon L Kaplan, MD
Glenn C Isaacson, MD, FAAP
Deputy Editor
Mary M Torchia, MD


Acute otitis media (AOM) is defined by moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to acute otitis externa accompanied by acute signs of illness and signs or symptoms of middle ear inflammation [1]. (See "Acute otitis media in children: Diagnosis", section on 'Acute otitis media'.)

The epidemiology and microbiology of AOM in the United States have been influenced by several factors, including:

Introduction of the 7-valent pneumococcal conjugate vaccine (PCV7) in 2000 and the 13-valent pneumococcal conjugate vaccine in 2010

Publication of guidelines by the American Academy of Pediatrics and the American Academy of Family Physicians (AAFP) in 2004 and updated in 2013, which provided detailed diagnostic criteria for AOM [1,2]

The educational campaign of the Centers for Disease Control and Prevention (CDC) and other authoritative groups to influence parents and clinicians to avoid inappropriate usage of antimicrobial agents for uncertain diagnoses of AOM [3]

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Literature review current through: Nov 2017. | This topic last updated: Sep 07, 2017.
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  1. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013; 131:e964.
  2. American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004; 113:1451.
  3. CDC. Get smart: Know when antibiotics work. Otitis media: Physician information sheet (pediatrics) http://www.cdc.gov/getsmart/campaign-materials/info-sheets/child-otitismedia.html (Accessed on February 09, 2011).
  4. Hoover H, Roddey OF. The overlooked importance of tympanic membrane bulging. Pediatrics 2005; 115:513; author reply 513.
  5. Rothman R, Owens T, Simel DL. Does this child have acute otitis media? JAMA 2003; 290:1633.
  6. Shaikh N, Hoberman A, Kaleida PH, et al. Otoscopic signs of otitis media. Pediatr Infect Dis J 2011; 30:822.
  7. Shaikh N, Hoberman A, Rockette HE, Kurs-Lasky M. Development of an algorithm for the diagnosis of otitis media. Acad Pediatr 2012; 12:214.
  8. Nyquist AC, Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998; 279:875.
  9. Coker TR, Chan LS, Newberry SJ, et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: a systematic review. JAMA 2010; 304:2161.
  10. Soni, A. Ear infections (otitis media) in children (0-17): use and expenditures, 2006. Statistical Brief No. 228. Agency for Healthcare Research and Quality Website. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st228/stat228.pdf (Accessed on January 12, 2011).
  11. Todberg T, Koch A, Andersson M, et al. Incidence of otitis media in a contemporary Danish National Birth Cohort. PLoS One 2014; 9:e111732.
  12. Teele DW, Klein JO, Rosner B. Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study. J Infect Dis 1989; 160:83.
  13. Kaur R, Morris M, Pichichero ME. Epidemiology of Acute Otitis Media in the Postpneumococcal Conjugate Vaccine Era. Pediatrics 2017; 140.
  14. Marom T, Tan A, Wilkinson GS, et al. Trends in otitis media-related health care use in the United States, 2001-2011. JAMA Pediatr 2014; 168:68.
  15. Eskola J, Kilpi T, Palmu A, et al. Efficacy of a pneumococcal conjugate vaccine against acute otitis media. N Engl J Med 2001; 344:403.
  16. Black S, Shinefield H, Fireman B, et al. Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Northern California Kaiser Permanente Vaccine Study Center Group. Pediatr Infect Dis J 2000; 19:187.
  17. Poehling KA, Lafleur BJ, Szilagyi PG, et al. Population-based impact of pneumococcal conjugate vaccine in young children. Pediatrics 2004; 114:755.
  18. Bluestone CD, Klein JO. Epidemiology. In: Otitis media in infants and children, 4th ed, BC Decker, Hamilton, ON 2007. p.73.
  19. Uhari M, Mäntysaari K, Niemelä M. A meta-analytic review of the risk factors for acute otitis media. Clin Infect Dis 1996; 22:1079.
  20. Casselbrant ML, Mandel EM, Fall PA, et al. The heritability of otitis media: a twin and triplet study. JAMA 1999; 282:2125.
  21. Patel JA, Nair S, Revai K, et al. Association of proinflammatory cytokine gene polymorphisms with susceptibility to otitis media. Pediatrics 2006; 118:2273.
  22. Emonts M, Wiertsema SP, Veenhoven RH, et al. The 4G/4G plasminogen activator inhibitor-1 genotype is associated with frequent recurrence of acute otitis media. Pediatrics 2007; 120:e317.
  23. Emonts M, Veenhoven RH, Wiertsema SP, et al. Genetic polymorphisms in immunoresponse genes TNFA, IL6, IL10, and TLR4 are associated with recurrent acute otitis media. Pediatrics 2007; 120:814.
  24. Nokso-Koivisto J, Chonmaitree T, Jennings K, et al. Polymorphisms of immunity genes and susceptibility to otitis media in children. PLoS One 2014; 9:e93930.
  25. Ladomenou F, Kafatos A, Tselentis Y, Galanakis E. Predisposing factors for acute otitis media in infancy. J Infect 2010; 61:49.
  26. Dewey C, Midgeley E, Maw R. The relationship between otitis media with effusion and contact with other children in a british cohort studied from 8 months to 3 1/2 years. The ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood. Int J Pediatr Otorhinolaryngol 2000; 55:33.
  27. Rovers MM, Zielhuis GA, Ingels K, van der Wilt GJ. Day-care and otitis media in young children: a critical overview. Eur J Pediatr 1999; 158:1.
  28. Wald ER, Dashefsky B, Byers C, et al. Frequency and severity of infections in day care. J Pediatr 1988; 112:540.
  29. Chonmaitree T, Trujillo R, Jennings K, et al. Acute Otitis Media and Other Complications of Viral Respiratory Infection. Pediatrics 2016; 137.
  30. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep) 2007; :1.
  31. Bowatte G, Tham R, Allen KJ, et al. Breastfeeding and childhood acute otitis media: a systematic review and meta-analysis. Acta Paediatr 2015; 104:85.
  32. Paradise JL, Elster BA, Tan L. Evidence in infants with cleft palate that breast milk protects against otitis media. Pediatrics 1994; 94:853.
  33. Sabirov A, Casey JR, Murphy TF, Pichichero ME. Breast-feeding is associated with a reduced frequency of acute otitis media and high serum antibody levels against NTHi and outer membrane protein vaccine antigen candidate P6. Pediatr Res 2009; 66:565.
  34. Biesbroek G, Bosch AA, Wang X, et al. The impact of breastfeeding on nasopharyngeal microbial communities in infants. Am J Respir Crit Care Med 2014; 190:298.
  35. Strachan DP, Cook DG. Health effects of passive smoking. 4. Parental smoking, middle ear disease and adenotonsillectomy in children. Thorax 1998; 53:50.
  36. Greenberg D, Givon-Lavi N, Broides A, et al. The contribution of smoking and exposure to tobacco smoke to Streptococcus pneumoniae and Haemophilus influenzae carriage in children and their mothers. Clin Infect Dis 2006; 42:897.
  37. Murphy TF. Otitis media, bacterial colonization, and the smoking parent. Clin Infect Dis 2006; 42:904.
  38. MacIntyre EA, Karr CJ, Koehoorn M, et al. Residential air pollution and otitis media during the first two years of life. Epidemiology 2011; 22:81.
  39. Zemek R, Szyszkowicz M, Rowe BH. Air pollution and emergency department visits for otitis media: a case-crossover study in Edmonton, Canada. Environ Health Perspect 2010; 118:1631.
  40. Brauer M, Gehring U, Brunekreef B, et al. Traffic-related air pollution and otitis media. Environ Health Perspect 2006; 114:1414.
  41. Heinrich J, Raghuyamshi VS. Air pollution and otitis media: a review of evidence from epidemiologic studies. Curr Allergy Asthma Rep 2004; 4:302.
  42. Kim PE, Musher DM, Glezen WP, et al. Association of invasive pneumococcal disease with season, atmospheric conditions, air pollution, and the isolation of respiratory viruses. Clin Infect Dis 1996; 22:100.
  43. Bluestone CD. Epidemiology and pathogenesis of chronic suppurative otitis media: implications for prevention and treatment. Int J Pediatr Otorhinolaryngol 1998; 42:207.
  44. Leach AJ, Wigger C, Andrews R, et al. Otitis media in children vaccinated during consecutive 7-valent or 10-valent pneumococcal conjugate vaccination schedules. BMC Pediatr 2014; 14:200.
  45. Morris PS, Leach AJ, Silberberg P, et al. Otitis media in young Aboriginal children from remote communities in Northern and Central Australia: a cross-sectional survey. BMC Pediatr 2005; 5:27.
  46. Dagan R, Leibovitz E, Greenberg D, et al. Mixed pneumococcal-nontypeable Haemophilus influenzae otitis media is a distinct clinical entity with unique epidemiologic characteristics and pneumococcal serotype distribution. J Infect Dis 2013; 208:1152.
  47. Minja BM, Machemba A. Prevalence of otitis media, hearing impairment and cerumen impaction among school children in rural and urban Dar es Salaam, Tanzania. Int J Pediatr Otorhinolaryngol 1996; 37:29.
  48. Rovers MM, Schilder AG, Zielhuis GA, Rosenfeld RM. Otitis media. Lancet 2004; 363:465.
  49. Winther B, Alper CM, Mandel EM, et al. Temporal relationships between colds, upper respiratory viruses detected by polymerase chain reaction, and otitis media in young children followed through a typical cold season. Pediatrics 2007; 119:1069.
  50. Revai K, Mamidi D, Chonmaitree T. Association of nasopharyngeal bacterial colonization during upper respiratory tract infection and the development of acute otitis media. Clin Infect Dis 2008; 46:e34.
  51. Alper CM, Winther B, Mandel EM, et al. Rate of concurrent otitis media in upper respiratory tract infections with specific viruses. Arch Otolaryngol Head Neck Surg 2009; 135:17.
  52. Lysenko ES, Ratner AJ, Nelson AL, Weiser JN. The role of innate immune responses in the outcome of interspecies competition for colonization of mucosal surfaces. PLoS Pathog 2005; 1:e1.
  53. Leach AJ, Boswell JB, Asche V, et al. Bacterial colonization of the nasopharynx predicts very early onset and persistence of otitis media in Australian aboriginal infants. Pediatr Infect Dis J 1994; 13:983.
  54. Bluestone CD, Klein JO. Microbiology. In: Otitis Media in Infants and Children, 4th ed, BC Decker, Hamilton, ON 2007. p.101.
  55. Pichichero ME. Ten-Year Study of the Stringently Defined Otitis-prone Child in Rochester, NY. Pediatr Infect Dis J 2016; 35:1033.
  56. Ngo CC, Massa HM, Thornton RB, Cripps AW. Predominant Bacteria Detected from the Middle Ear Fluid of Children Experiencing Otitis Media: A Systematic Review. PLoS One 2016; 11:e0150949.
  57. Ruohola A, Meurman O, Nikkari S, et al. Microbiology of acute otitis media in children with tympanostomy tubes: prevalences of bacteria and viruses. Clin Infect Dis 2006; 43:1417.
  58. Kaur R, Adlowitz DG, Casey JR, et al. Simultaneous assay for four bacterial species including Alloiococcus otitidis using multiplex-PCR in children with culture negative acute otitis media. Pediatr Infect Dis J 2010; 29:741.
  59. Chonmaitree T. Acute otitis media is not a pure bacterial disease. Clin Infect Dis 2006; 43:1423.
  60. Chonmaitree T, Owen MJ, Patel JA, et al. Effect of viral respiratory tract infection on outcome of acute otitis media. J Pediatr 1992; 120:856.
  61. Chonmaitree T, Owen MJ, Howie VM. Respiratory viruses interfere with bacteriologic response to antibiotic in children with acute otitis media. J Infect Dis 1990; 162:546.
  62. Chonmaitree T, Patel JA, Lett-Brown MA, et al. Virus and bacteria enhance histamine production in middle ear fluids of children with acute otitis media. J Infect Dis 1994; 169:1265.
  63. Chonmaitree T, Patel JA, Sim T, et al. Role of leukotriene B4 and interleukin-8 in acute bacterial and viral otitis media. Ann Otol Rhinol Laryngol 1996; 105:968.
  64. Abramson JS, Giebink GS, Quie PG. Influenza A virus-induced polymorphonuclear leukocyte dysfunction in the pathogenesis of experimental pneumococcal otitis media. Infect Immun 1982; 36:289.
  65. Canafax DM, Yuan Z, Chonmaitree T, et al. Amoxicillin middle ear fluid penetration and pharmacokinetics in children with acute otitis media. Pediatr Infect Dis J 1998; 17:149.
  66. Casey JR, Pichichero ME. Changes in frequency and pathogens causing acute otitis media in 1995-2003. Pediatr Infect Dis J 2004; 23:824.
  67. Pichichero ME, Casey JR, Hoberman A, Schwartz R. Pathogens causing recurrent and difficult-to-treat acute otitis media, 2003-2006. Clin Pediatr (Phila) 2008; 47:901.
  68. Casey JR, Adlowitz DG, Pichichero ME. New patterns in the otopathogens causing acute otitis media six to eight years after introduction of pneumococcal conjugate vaccine. Pediatr Infect Dis J 2010; 29:304.
  69. Pichichero ME. Ten-Year Study of Acute Otitis Media in Rochester, NY. Pediatr Infect Dis J 2016; 35:1027.
  70. Block SL, Hedrick J, Harrison CJ, et al. Community-wide vaccination with the heptavalent pneumococcal conjugate significantly alters the microbiology of acute otitis media. Pediatr Infect Dis J 2004; 23:829.
  71. McCormick DP, Chandler SM, Chonmaitree T. Laterality of acute otitis media: different clinical and microbiologic characteristics. Pediatr Infect Dis J 2007; 26:583.
  72. Leibovitz E, Asher E, Piglansky L, et al. Is bilateral acute otitis media clinically different than unilateral acute otitis media? Pediatr Infect Dis J 2007; 26:589.
  73. Ben-Shimol S, Givon-Lavi N, Leibovitz E, et al. Near-elimination of otitis media caused by 13-valent pneumococcal conjugate vaccine (PCV) serotypes in southern Israel shortly after sequential introduction of 7-valent/13-valent PCV. Clin Infect Dis 2014; 59:1724.
  74. Marchisio P, Esposito S, Picca M, et al. Serotypes not Included in 13-Valent Pneumococcal Vaccine as Causes of Acute Otitis Media with Spontaneous Tympanic Membrane Perforation in a Geographic Area with High Vaccination Coverage. Pediatr Infect Dis J 2017; 36:521.
  75. Palmu AA, Herva E, Savolainen H, et al. Association of clinical signs and symptoms with bacterial findings in acute otitis media. Clin Infect Dis 2004; 38:234.
  76. Kilpi T, Herva E, Kaijalainen T, et al. Bacteriology of acute otitis media in a cohort of Finnish children followed for the first two years of life. Pediatr Infect Dis J 2001; 20:654.
  77. Rodriguez WJ, Schwartz RH. Streptococcus pneumoniae causes otitis media with higher fever and more redness of tympanic membranes than Haemophilus influenzae or Moraxella catarrhalis. Pediatr Infect Dis J 1999; 18:942.
  78. Hausdorff WP, Yothers G, Dagan R, et al. Multinational study of pneumococcal serotypes causing acute otitis media in children. Pediatr Infect Dis J 2002; 21:1008.
  79. Pichichero ME, Casey JR. Emergence of a multiresistant serotype 19A pneumococcal strain not included in the 7-valent conjugate vaccine as an otopathogen in children. JAMA 2007; 298:1772.
  80. McEllistrem MC, Adams JM, Patel K, et al. Acute otitis media due to penicillin-nonsusceptible Streptococcus pneumoniae before and after the introduction of the pneumococcal conjugate vaccine. Clin Infect Dis 2005; 40:1738.
  81. Couloigner V, Levy C, François M, et al. Pathogens implicated in acute otitis media failures after 7-valent pneumococcal conjugate vaccine implementation in France: distribution, serotypes, and resistance levels. Pediatr Infect Dis J 2012; 31:154.
  82. Xu Q, Pichichero ME, Casey JR, Zeng M. Novel type of Streptococcus pneumoniae causing multidrug-resistant acute otitis media in children. Emerg Infect Dis 2009; 15:547.
  83. Ongkasuwan J, Valdez TA, Hulten KG, et al. Pneumococcal mastoiditis in children and the emergence of multidrug-resistant serotype 19A isolates. Pediatrics 2008; 122:34.
  84. Cohen R, Levy C, Bingen E, et al. Impact of 13-valent pneumococcal conjugate vaccine on pneumococcal nasopharyngeal carriage in children with acute otitis media. Pediatr Infect Dis J 2012; 31:297.
  85. Pelton SI, et al. Presentation at IDWeek, 2012, San Diego, CA.
  86. Martin JM, Hoberman A, Paradise JL, et al. Emergence of Streptococcus pneumoniae serogroups 15 and 35 in nasopharyngeal cultures from young children with acute otitis media. Pediatr Infect Dis J 2014; 33:e286.
  87. Dagan R, Pelton S, Bakaletz L, Cohen R. Prevention of early episodes of otitis media by pneumococcal vaccines might reduce progression to complex disease. Lancet Infect Dis 2016; 16:480.
  88. Barkai G, Leibovitz E, Givon-Lavi N, Dagan R. Potential contribution by nontypable Haemophilus influenzae in protracted and recurrent acute otitis media. Pediatr Infect Dis J 2009; 28:466.
  89. Mills N, Best EJ, Murdoch D, et al. What is behind the ear drum? The microbiology of otitis media and the nasopharyngeal flora in children in the era of pneumococcal vaccination. J Paediatr Child Health 2015; 51:300.
  90. Bluestone CD, Stephenson JS, Martin LM. Ten-year review of otitis media pathogens. Pediatr Infect Dis J 1992; 11:S7.
  91. Brook I, Gober AE. Bacteriology of spontaneously draining acute otitis media in children before and after the introduction of pneumococcal vaccination. Pediatr Infect Dis J 2009; 28:640.
  92. Segal N, Givon-Lavi N, Leibovitz E, et al. Acute otitis media caused by Streptococcus pyogenes in children. Clin Infect Dis 2005; 41:35.
  93. Leibovitz E, Serebro M, Givon-Lavi N, et al. Epidemiologic and microbiologic characteristics of culture-positive spontaneous otorrhea in children with acute otitis media. Pediatr Infect Dis J 2009; 28:381.
  94. Klein J, Chan S. Methicillin-resistant Staphylococcus aureus in middle ear fluid of children. Clin Pediatr (Phila) 2010; 49:66.
  95. Veenhoven R, Bogaert D, Uiterwaal C, et al. Effect of conjugate pneumococcal vaccine followed by polysaccharide pneumococcal vaccine on recurrent acute otitis media: a randomised study. Lancet 2003; 361:2189.
  96. Turner D, Leibovitz E, Aran A, et al. Acute otitis media in infants younger than two months of age: microbiology, clinical presentation and therapeutic approach. Pediatr Infect Dis J 2002; 21:669.
  97. Nozicka CA, Hanly JG, Beste DJ, et al. Otitis media in infants aged 0-8 weeks: frequency of associated serious bacterial disease. Pediatr Emerg Care 1999; 15:252.
  98. Heikkinen T, Thint M, Chonmaitree T. Prevalence of various respiratory viruses in the middle ear during acute otitis media. N Engl J Med 1999; 340:260.
  99. Ruuskanen O, Arola M, Heikkinen T, Ziegler T. Viruses in acute otitis media: increasing evidence for clinical significance. Pediatr Infect Dis J 1991; 10:425.
  100. Pitkäranta A, Virolainen A, Jero J, et al. Detection of rhinovirus, respiratory syncytial virus, and coronavirus infections in acute otitis media by reverse transcriptase polymerase chain reaction. Pediatrics 1998; 102:291.
  101. Heikkinen T, Silvennoinen H, Peltola V, et al. Burden of influenza in children in the community. J Infect Dis 2004; 190:1369.
  102. Stockmann C, Ampofo K, Hersh AL, et al. Seasonality of acute otitis media and the role of respiratory viral activity in children. Pediatr Infect Dis J 2013; 32:314.
  103. Barnett ED, Klein JO. Bacterial infections of the respiratory tract. In: Infectious Diseases of the Fetus and Newborn Infant, 7th, Remington JS, Klein JO, Wilson CB, et al (Eds), Elsevier Saunders, Philadelphia 2011. p.276.
  104. Balkany TJ, Berman SA, Simmons MA, Jafek BW. Middle ear effusions in neonates. Laryngoscope 1978; 88:398.
  105. Berman SA, Balkany TJ, Simmons MA. Otitis media in the neonatal intensive care unit. Pediatrics 1978; 62:198.
  106. Bland RD. Otitis media in the first six weeks of life: diagnosis, bacteriology, and management. Pediatrics 1972; 49:187.
  107. Tetzlaff TR, Ashworth C, Nelson JD. Otitis media in children less than 12 weeks of age. Pediatrics 1977; 59:827.
  108. Shurin PA, Howie VM, Pelton SI, et al. Bacterial etiology of otitis media during the first six weeks of life. J Pediatr 1978; 92:893.
  109. Karma PH, Pukander JS, Sipilä MM, et al. Middle ear fluid bacteriology of acute otitis media in neonates and very young infants. Int J Pediatr Otorhinolaryngol 1987; 14:141.
  110. Berman S. Otitis media in developing countries. Pediatrics 1995; 96:126.
  111. Working Group of the Infectious Diseases Society of Southern Africa. Updated guideline for the management of upper respiratory tract infections in South Africa: 2008. South Afr J Epidemiol Infect 2008; 23:27.
  112. Ding Y, Geng Q, Tao Y, et al. Etiology and epidemiology of children with acute otitis media and spontaneous otorrhea in Suzhou, China. Pediatr Infect Dis J 2015; 34:e102.
  113. Niemela M, Uhari M, Jounio-Ervasti K, et al. Lack of specific symptomatology in children with acute otitis media. Pediatr Infect Dis J 1994; 13:765.
  114. Kontiokari T, Koivunen P, Niemelä M, et al. Symptoms of acute otitis media. Pediatr Infect Dis J 1998; 17:676.
  115. Laine MK, Tähtinen PA, Ruuskanen O, et al. Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age. Pediatrics 2010; 125:e1154.
  116. Bluestone CD, Klein JO. Diagnosis. In: Otitis Media in Infants and Children, 4th ed, BC Decker, Hamilton, ON 2007. p.147.
  117. McCormick DP, Jennings K, Ede LC, et al. Use of symptoms and risk factors to predict acute otitis media in infants. Int J Pediatr Otorhinolaryngol 2016; 81:55.
  118. Schwartz RH, Rodriguez WJ, Brook I, Grundfast KM. The febrile response in acute otitis media. JAMA 1981; 245:2057.
  119. Hayden GF, Schwartz RH. Characteristics of earache among children with acute otitis media. Am J Dis Child 1985; 139:721.
  120. Buznach N, Dagan R, Greenberg D. Clinical and bacterial characteristics of acute bacterial conjunctivitis in children in the antibiotic resistance era. Pediatr Infect Dis J 2005; 24:823.
  121. Block SL, Hedrick J, Tyler R, et al. Increasing bacterial resistance in pediatric acute conjunctivitis (1997-1998). Antimicrob Agents Chemother 2000; 44:1650.
  122. Bodor FF. Conjunctivitis-otitis syndrome. Pediatrics 1982; 69:695.
  123. Bingen E, Cohen R, Jourenkova N, Gehanno P. Epidemiologic study of conjunctivitis-otitis syndrome. Pediatr Infect Dis J 2005; 24:731.
  124. Murphy TF, Faden H, Bakaletz LO, et al. Nontypeable Haemophilus influenzae as a pathogen in children. Pediatr Infect Dis J 2009; 28:43.
  125. Kotikoski MJ, Palmu AA, Nokso-Koivisto J, Kleemola M. Evaluation of the role of respiratory viruses in acute myringitis in children less than two years of age. Pediatr Infect Dis J 2002; 21:636.
  126. McCormick DP, Saeed KA, Pittman C, et al. Bullous myringitis: a case-control study. Pediatrics 2003; 112:982.
  127. Kotikoski MJ, Kleemola M, Palmu AA. No evidence of Mycoplasma pneumoniae in acute myringitis. Pediatr Infect Dis J 2004; 23:465.
  128. Merifield DO, Miller GS. The etiology and clinical course of bullous myringitis. Arch Otolaryngol 1966; 84:487.
  129. Roberts DB. The etiology of bullous myringitis and the role of mycoplasmas in ear disease: a review. Pediatrics 1980; 65:761.
  130. Hahn HB Jr, Riggs MW, Hutchinson LR. Myringitis bullosa. Clin Pediatr (Phila) 1998; 37:265.
  131. Palmu AA, Kotikoski MJ, Kaijalainen TH, Puhakka HJ. Bacterial etiology of acute myringitis in children less than two years of age. Pediatr Infect Dis J 2001; 20:607.
  132. Alonso M, Marimon JM, Ercibengoa M, et al. Dynamics of Streptococcus pneumoniae serotypes causing acute otitis media isolated from children with spontaneous middle-ear drainage over a 12-year period (1999-2010) in a region of northern Spain. PLoS One 2013; 8:e54333.
  133. García-Cobos S, Moscoso M, Pumarola F, et al. Frequent carriage of resistance mechanisms to β-lactams and biofilm formation in Haemophilus influenzae causing treatment failure and recurrent otitis media in young children. J Antimicrob Chemother 2014; 69:2394.
  134. Thornton RB, Rigby PJ, Wiertsema SP, et al. Multi-species bacterial biofilm and intracellular infection in otitis media. BMC Pediatr 2011; 11:94.
  135. Bluestone CD. Clinical course, complications and sequelae of acute otitis media. Pediatr Infect Dis J 2000; 19:S37.
  136. Bluestone CD, Klein JO. Complications and sequelae: Intratemporal. In: Otitis media in infants an children, 4th ed, BC Decker, Hamilton, ON 2007. p.327.
  137. Teele DW, Klein JO, Chase C, et al. Otitis media in infancy and intellectual ability, school achievement, speech, and language at age 7 years. Greater Boston Otitis Media Study Group. J Infect Dis 1990; 162:685.
  138. Klausen O, Møller P, Holmefjord A, et al. Lasting effects of otitis media with effusion on language skills and listening performance. Acta Otolaryngol Suppl 2000; 543:73.
  139. Petinou KC, Schwartz RG, Gravel JS, Raphael LJ. A preliminary account of phonological and morphophonological perception in young children with and without otitis media. Int J Lang Commun Disord 2001; 36:21.
  140. Bennett KE, Haggard MP, Silva PA, Stewart IA. Behaviour and developmental effects of otitis media with effusion into the teens. Arch Dis Child 2001; 85:91.
  141. Paradise JL, Feldman HM, Campbell TF, et al. Effect of early or delayed insertion of tympanostomy tubes for persistent otitis media on developmental outcomes at the age of three years. N Engl J Med 2001; 344:1179.
  142. Paradise JL, Feldman HM, Campbell TF, et al. Early versus delayed insertion of tympanostomy tubes for persistent otitis media: developmental outcomes at the age of three years in relation to prerandomization illness patterns and hearing levels. Pediatr Infect Dis J 2003; 22:309.
  143. Paradise JL, Dollaghan CA, Campbell TF, et al. Otitis media and tympanostomy tube insertion during the first three years of life: developmental outcomes at the age of four years. Pediatrics 2003; 112:265.
  144. Paradise JL, Campbell TF, Dollaghan CA, et al. Developmental outcomes after early or delayed insertion of tympanostomy tubes. N Engl J Med 2005; 353:576.
  145. Paradise JL, Feldman HM, Campbell TF, et al. Tympanostomy tubes and developmental outcomes at 9 to 11 years of age. N Engl J Med 2007; 356:248.
  146. Roberts JE, Rosenfeld RM, Zeisel SA. Otitis media and speech and language: a meta-analysis of prospective studies. Pediatrics 2004; 113:e238.
  147. Casby MW. Otitis media and language development: a meta-analysis. Am J Speech Lang Pathol 2001; 10:65.
  148. Shekelle P, Takata G, Chan L, et al. Diagnosis, natural history, and late effects of otitis media with effusion. Evidence Report/Technology Assessment No. 55. Agency for Healthcare Research and Quality 2003. http://archive.ahrq.gov/downloads/pub/evidence/pdf/otdiag/otdiag.pdf (Accessed on February 28, 2011).
  149. Gawron W, Pośpiech L, Orendorz-Fraczkowska K. An evaluation of postural stability and the effects of middle-ear drainage on vestibulo-spinal reflexes of children with chronic otitis media with effusion. Int J Pediatr Otorhinolaryngol 2004; 68:1175.
  150. Casselbrant ML, Furman JM, Rubenstein E, Mandel EM. Effect of otitis media on the vestibular system in children. Ann Otol Rhinol Laryngol 1995; 104:620.
  151. Golz A, Westerman ST, Gilbert LM, et al. Effect of middle ear effusion on the vestibular labyrinth. J Laryngol Otol 1991; 105:987.
  152. Golz A, Angel-Yeger B, Parush S. Evaluation of balance disturbances in children with middle ear effusion. Int J Pediatr Otorhinolaryngol 1998; 43:21.
  153. Tähtinen PA, Laine MK, Huovinen P, et al. A placebo-controlled trial of antimicrobial treatment for acute otitis media. N Engl J Med 2011; 364:116.
  154. Hoberman A, Paradise JL, Rockette HE, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med 2011; 364:105.
  155. Penido Nde O, Borin A, Iha LC, et al. Intracranial complications of otitis media: 15 years of experience in 33 patients. Otolaryngol Head Neck Surg 2005; 132:37.