Otitis media is an infection of the middle ear space, behind the eardrum (tympanic membrane). It is characterized by pain, dizziness, and partial loss of hearing.
A little knowledge of the basic anatomy of the middle ear will be helpful for understanding the development of otitis media. The external ear canal is that tube which leads from the outside opening of the ear to the structure called the tympanic membrane. Behind the tympanic membrane is the space called the middle ear. Within the middle ear are three tiny bones, called ossicles. Sound (in the form of vibration) causes movement in the eardrum, and then the ossicles. The ossicles transmit the sound to a structure within the inner ear, which sends it to the brain for processing.
The nasopharynx is that passageway behind the nose which takes inhaled air into the breathing tubes leading to the lungs. The eustachian tube is a canal which runs between the middle ear and the nasopharynx. One of the functions of the eustachian tube is to keep the air pressure in the middle ear equal to that outside. This allows the eardrum and ossicles to vibrate appropriately, so that hearing is normal.
By age three, almost 85% of all children will have had otitis media at least once. Babies and children between the ages of six months and six years are most likely to develop otitis media. Children at higher risk factors for otitis media include boys, children from poor families, Native Americans, Native Alaskans, children born with cleft palate or other defects of the structures of the head and face, and children with Down syndrome. Exposure to cigarette smoke significantly increases the risk of otitis media as well as other problems affecting the respiratory system. Also, children who enter daycare at an early age have more upper respiratory infections (URIs or colds), and thus more cases of otitis media. The most usual times of year for otitis media to strike are in winter and early spring (the same times URIs are most common).
Otitis media is an important problem, because it often results in fluid accumulation within the middle ear (effusion). The effusion can last for weeks to months. Effusion within the middle ear can cause significant hearing impairment. When such hearing impairment occurs in a young child, it may interfere with the development of normal speech.
In adults, acute otitis media can lead to such complications as paralysis of the facial nerves. Recovery from these complications may take from two weeks to as long as three months.
Causes and symptoms
The first precondition for the development of acute otitis media is exposure to an organism capable of causing the infection. Otitis media can be caused by either viruses or bacteria. Virus infections account for about 15% of cases. The three most common bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis. As of 2003, about 75% of ear infections caused by S. pneumoniae are reported to be penicillin-resistant.
Otitis media may also be caused by other disease organisms, including Bordetella pertussis, the causative agent of whooping cough, and Pneumocystis carinii, which often causes opportunistic infections in patients with AIDS.
There are other factors which make the development of an ear infection more likely. Because the eustachian tube has a more horizontal orientation and is considerably shorter in early childhood, material from the nasopharynx (including infection-causing organisms) is better able to reach the middle ear. Children also have a lot of lymph tissue (commonly called the adenoids) in the area of the eustachian tube. These adenoids may enlarge with repeated respiratory tract infections (colds), ultimately blocking the eustachian tubes. When the eustachian tube is blocked, the middle ear is more likely to fill with fluid. This fluid, then, increases the risk of infection, and the risk of hearing loss and delayed speech development.
Most cases of acute otitis media occur during the course of a URI. Symptoms include fever, ear pain, and problems with hearing. Babies may have difficulty feeding. When significant fluid is present within the middle ear, pain may increase depending on position. Lying down may cause an increase in painful pressure within the middle ear, so that babies may fuss if not held upright. If the fluid build-up behind the eardrum is sufficient, the eardrum may develop a hole (perforate), causing bloody fluid or greenish-yellow pus to drip from the ear. Although pain may be significant leading up to such a perforation, the pain is usually relieved by the reduction of pressure brought on by a perforation.
Recent advances in gene mapping have led to the discovery of genetic factors that increase a child's susceptibility to otitis media. Researchers are hoping to develop molecular diagnostic assays that will help to identify children at risk for severe ear infections.
Diagnosis is usually made simply by looking at the eardrum through a special lighted instrument called an otoscope. The eardrum will appear red and swollen, and may appear either abnormally drawn inward, or bulging outward. Under normal conditions, the ossicles create a particular pattern on the eardrum, referred to as "landmarks." These landmarks may be obscured. Normally, the light from the otoscope reflects off of the eardrum in a characteristic fashion. This is called the "cone of light." In an infection, this cone of light may be shifted or absent.
A special attachment to the otoscope allows a puff of air to be blown lightly into the ear. Normally, this should cause movement of the eardrum. In an infection, or when there is fluid behind the eardrum, this movement may be decreased or absent.
If fluid or pus is draining from the ear, it can be collected. This sample can then be processed in a laboratory to allow any organisms present to multiply sufficiently (cultured) to permit the organisms to be viewed under a microscope and identified.
Antibiotics are the treatment of choice for acute otitis media (AOM). Different antibiotics are used depending on the type of bacteria most likely to be causing the infection. This decision involves knowledge of the types of antibiotics that have worked on other ear infections occurring within a particular community at a particular time. Options include sulfa-based antibiotics, as well as a variety of penicillins, cephalosporins, and others. The patient's sensitivity to certain medications, as well as previously demonstrated resistant strains, also contributes to the choice of antibiotic. As of 2003, an 0.3% topical solution of ofloxacin has been recommended as a more effective medication than other oral or topical antibiotics.
Some controversy exists regarding whether overuse of antibiotics is actually contributing to the development of bacteria, which may evolve and become able to avoid being killed by antibiotics. Research is being done to try to help determine whether there may be some ear infections that will clear up without antibiotic treatment. In the meantime, the classic treatment of an ear infection continues to involve a seven to 10-day course of antibiotic medication.
Some medical practitioners prescribe the use of special nosedrops, decongestants, or antihistamines to improve the functioning of the eustachian tube.
Whether or not antibiotics are used, such pain relievers as Tylenol or Motrin can be very helpful in reducing the pain and inflammation associated with otitis media.
In a few rare cases, a surgical perforation to drain the middle ear of pus may be performed. This procedure is called a myringotomy. The hole created by the myringotomy generally heals itself in about a week. In 2002 a new minimally invasive procedure was introduced that uses a laser to perform the myringotomy. It can be performed in the doctor's office and heals more rapidly than the standard myringotomy.
Although some doctors have recommended removing the adenoids to prevent recurrent otitis media in young children, recent studies indicate that surgical removal of the adenoids does not appear to offer any advantages over a myringotomy as a preventive measure.
Some practitioners believe that food allergies may increase the risk of ear infections, and they suggest eliminating suspected food allergens from the diet. The top food allergens are wheat, dairy products, corn, peanuts, citrus fruits, and eggs. Elimination of sugar and sugar products can allow the immune system to work more effectively. A number of herbal treatments have been recommended, including ear drops made with goldenseal (Hydrastis canadensis ), mullein (Verbascum thapsus ), St. John's wort (Hypericum perforatum ), and echinacea (Echinacea spp.). Among the herbs often recommended for oral treatment of otitis media are echinacea and cleavers (Galium aparine ), or black cohosh (Cimicifuga racemosa ) and ginkgo (Ginkgo biloba ). Homeopathic remedies that may be prescribed include aconite (Acontium napellus), Ferrum phosphoricum, belladonna, chamomile, Lycopodium, pulsatilla (Pulsatilla nigricans ), or silica. Craniosacral therapy uses gentle manipulation of the bones of the skull to relieve pressure and improve eustachian tube function.
With treatment, the prognosis for acute otitis media is very good. However, long-lasting accumulations of fluid within the middle ear are a risk both for difficulties with hearing and speech, and for the repeated development of ear infections. Furthermore, without treatment, otitis media can lead to an infection within the nearby mastoid bone, called mastoiditis.
Although otitis media seems somewhat inevitable in childhood, some measures can be taken to decrease the chance of repeated infections and fluid accumulation. Breastfeeding provides some protection against URIs, which in turn protects against the development of otitis media. If a child is bottle-fed, parents should be advised to feed him or her upright, rather than allowing the baby to lie down with the bottle. General good hygiene practices (especially handwashing) help to decrease the number of upper respiratory infections in a household or daycare center.
The use of pacifiers should be avoided or limited. They may act as fomites, particularly in a daycare setting. In children who are more susceptible to otitis media, pacifier use can increase by as much as 50% the number of ear infections experienced.
Two vaccines can prevent otitis media associated with certain strains of bacteria. One is designed to prevent meningitis and other diseases, including otitis media, that result from infection with Haemophilus influenzae type B. Another is a vaccine against Streptococcus pneumoniae, a very common cause of otitis media. Children who are at high risk or have had severe or chronic infections may be good candidates for these vaccines; in fact, a recent consensus report among pediatricians recommended routine administration of the pneumococcal conjugate vaccine to children younger than two years, as well as those at high risk for AOM. Parents should consult a health care provider concerning the advisability of this treatment.
Another vaccine that appears to lower the risk of AOM in children is the intranasal vaccine that was recently introduced for preventing influenza. Although the flu vaccine was not developed to prevent AOM directly, one team of researchers found that children who were given the vaccine before the start of flu season were 43% less likely to develop AOM than children who were not vaccinated.
As of early 2003, there is no vaccine effective against M. catarrhalis. Researchers are working on developing such a vaccine, as well as a tribacterial vaccine that would be effective against all three pathogens that commonly cause otitis media.
A nutrition-based approach to preventive treatment is undergoing clinical trials as of late 2002. This treatment involves giving children a dietary supplement of lemon-flavored cod liver oil plus a multivitamin formula containing selenium. The pilot study found that children receiving the supplement had fewer cases of otitis media, and that those who did develop it recovered with a shorter course of antibiotic treatment than children who were not receiving the supplement.
After a child has completed treatment for otitis media, a return visit to the practitioner should be scheduled. This visit should occur after the antibiotic has been completed, and allows the practitioner to evaluate the patient for the persistent presence of fluid within the middle ear. In children who have a problem with recurrent otitis media, a small daily dose of an antibiotic may prevent repeated full attacks of otitis media. In children who have persistent fluid, a procedure to place tiny tubes within the eardrum may help equalize pressure between the middle ear and the outside, thus preventing further fluid accumulation.
Adenoid— A collection of lymph tissue located in the nasopharynx.
Effusion— A collection of fluid which has leaked out into some body cavity or tissue.
Eustachian tube— A small tube which runs between the middle ear space and the nasopharynx.
Fomite— An inanimate object that can transmit infectious organisms.
Myringotomy— A surgical procedure performed to drain an infected middle ear. A newer type of myringotomy uses a laser instead of a scalpel.
Nasopharynx— The part of the airway into which the nose leads.
Ossicles— Tiny bones located within the middle ear which are responsible for conveying the vibrations of sound through to the inner ear.
Perforation— A hole.
Topical— Referring to a medication applied to the skin or outward surface of the body. Ear drops are one type of topical medication.
Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part I: Chiropractic and Osteopathy. New York: Simon & Schuster, 2002.
Abes, G., N. Espallardo, M. Tong, et al. "A Systematic Review of the Effectiveness of Ofloxacin Otic Solution for the Treatment of Suppurative Otitis Media." ORL 65 (March-April 2003): 106-116.
Bucknam, J. A., and P. C. Weber. "Laser Assisted Myringotomy for Otitis Media with Effusion in Children." ORL-Head and Neck Nursing 20 (Summer 2002): 11-13.
Cripps, A. W., and J. Kyd. "Bacterial Otitis Media: Current Vaccine Development Strategies." Immunology and Cell Biology 81 (February 2003): 46-51.
Decherd, M. E., R. W. Deskin, J. L. Rowen, and M. B. Brindley. "Bordetella pertussis Causing Otitis Media: A Case Report." Laryngoscope 113 (February 2003): 226-227.
Goodwin, J. H., and J. C. Post. "The Genetics of Otitis Media." Current Allergy and Asthma Reports 2 (July 2002): 304-308.
Hoberman, A., C. D. Marchant, S. L. Kaplan, and S. Feldman. "Treatment of Acute Otitis Media Consensus Recommendations." Clinical Pediatrics 41 (July-August 2002): 373-390.
Linday, L. A., J. N. Dolitsky, R. D. Shindledecker, and C. E. Pippinger. "Lemon-Flavored Cod Liver Oil and a Multivitamin-Mineral Supplement for the Secondary Prevention of Otitis Media in Young Children: Pilot Research." Annals of Otology, Rhinology, and Laryngology 111 (July 2002): 642-652.
Marchisio, P., R. Cavagna, B. Maspes, et al. "Efficacy of Intranasal Virosomal Influenza Vaccine in the Prevention of Recurrent Acute Otitis Media in Children." Clinical Infectious Diseases 35 (July 15, 2002): 168-174.
Mattila, P. S., V. P. Joki-Erkkila, T. Kilpi, et al. "Prevention of Otitis Media by Adenoidectomy in Children Younger Than 2 Years." Archives of Otolaryngology—Head and Neck Surgery 129 (February 2003): 163-168.
Menger, D. J., and R. G. van den Berg. "Pneumocystis carinii Infection of the Middle Ear and External Auditory Canal. Report of a Case and Review of the Literature." ORL 65 (January-February 2003): 49-51.
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American Academy of Otolaryngology, Head and Neck Surgery, Inc. One Prince Street, Alexandria, VA 22314-3357. (703) 836-4444.
American Academy of Pediatrics (AAP). 141 Northwest Point Boulevard, Elk Grove Village, IL 60007. (847) 434-4000. 〈www.aap.org〉.
"Otitis Media." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. (February 21, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/otitis-media
"Otitis Media." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved February 21, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/otitis-media
Otitis media is an infection of the middle ear, which is located behind the eardrum. There are two main types of otitis media. In the first, called acute otitis media (AOM), parts of the ear are infected and swollen, and fluid and mucus are trapped inside the ear. AOM can be quite painful. In the second type, called otitis media with effusion (fluid), or OME, fluid and mucus remain trapped within the ear after the infection is over, making it more difficult for the ear to fight off new infections. This fluid may adversely affect a child's hearing.
One of the most common childhood infections, Otitis media is the leading cause of visits to the doctor by children. It is also the most frequent reason children receive antibiotic prescriptions or undergo surgery.
In order to fully understand otitis media, it is helpful to have a basic knowledge of ear anatomy. Deep within the outer ear canal is the eardrum, which is a thin, transparent membrane that vibrates in response to sound. Behind the eardrum is the space called the middle ear. When the eardrum vibrates, three tiny bones within the middle ear, called ossicles, transmit these sounds to the inner ear. Nerves are stimulated in the inner ear, which then relay the sound signals to the brain. The eustachian tube, which connects the middle ear to the nose, normally equalizes pressure in the middle ear, allowing the eardrum and ossicles to vibrate correctly, so that hearing is normal.
There are certain factors particular to children that make them more at risk for otitis media. In children, the eustachian tube is shorter and less slanted than in adults. Its size and position allow bacteria and viruses to travel to the middle ear more easily. Children also have clumps of infection fighting cells, commonly called adenoids, in the area of the eustachian tube. These adenoids may enlarge with repeated respiratory tract infections and ultimately block the eustachian tubes. When these tubes are blocked, the middle ear is more likely to fill with fluid, which in turn increases the risk for infection.
Otitis media is common. Fifty percent of children have an episode before their first birthday, and 80 percent of children have an occurrence by their third birthday. It is estimated that $3 to $4 billion are spent per year on patients with a diagnosis of acute otitis media and related complications. Ear infections are found in all age groups, but they are considerably more common in children, especially those aged six months to three years. Boys are affected more commonly than girls. Other children at higher risk include those from poor families, Native Americans, children born with cleft palate or other defects of the facial structures, and children with Down syndrome . Exposure to cigarette smoke and early entrance into daycare also increase the risk. Otitis media occurs more frequently in winter and early spring. It is less common among children who are breastfeeding. Some studies show a genetic predisposition towards developing otitis media.
Causes and symptoms
The first precondition for the development of acute otitis media is exposure to an organism capable of causing the infection. Otitis media may be caused by either viruses or bacteria. Viral infections account for approximately 15 percent of cases. The majority of other cases are caused by a variety of bacteria. The three most common bacteria are Streptococcus pneumoniae (responsible for 25–50% of cases), Haemophilus influenzae (15–30%), and Moraxella catarrhalis (3–20%).
Acute otitis media often occurs as an aftereffect of upper respiratory infections, in which the eustachian tube and nasal membranes become swollen and congested. This condition can lead to an impaired clearance and pressure regulation in the middle ear, which, if sustained, may be followed by viruses and bacteria traveling from the nasopharynx to the middle ear.
Otitis media with effusion may develop within weeks of an acute episode of middle ear infection, but in many cases the cause is unknown. It is often associated with an abnormal or malfunctioning eustachian tube, which causes negative pressure in the middle ear and leaking of fluid from tiny blood vessels, or capillaries, into the middle ear.
Symptoms of acute otitis media (AOM)
The following are symptoms of acute otitis media:
- ear pulling
- complaints of ear pain , ear fullness, or hearing loss by older children
- fussiness, irritability, or difficulties in hearing, feeding, or sleeping in younger children
- bloody or greenish-yellow pus draining from the ear (This seepage is the sign of a perforated the eardrum. The pain leading up to such a perforation may be severe, but it is often relieved by the rupture.)
Otitis media with effusion (OME) is the presence of middle ear fluid for six weeks or longer after the initial episode of acute otitis media. The hallmark of OME is the lack of obvious symptoms in those who most commonly have the condition. Older children often complain of muffled hearing or a sense of fullness in the ear. Younger children may turn up the television volume. Most often OME is diagnosed when someone examines the ear for another reason, such as a well-child physical. For this reason, OME is often referred to as silent otitis media.
When to call the doctor
Unresolved episodes of otitis media may lead to a variety of complications, including hearing loss and dizziness . Any child who reports an earache or a sense of fullness in the ear, especially if combined with a prior upper respiratory tract infection, or fever, should be evaluated by a physician.
The physician will visualize the ear canal and ear drum by using a special lighted instrument called an otoscope. Normally, the light from the otoscope reflects off the eardrum in a characteristic fashion called the "cone of light." In an infection, this reflection is often shifted or absent. If fluid or pus is draining from the ear, it can be collected and sent to a laboratory to determine if any specific infectious organisms are present. Additionally, a tympanometry test will be performed. Here, the doctor inserts a probe into the ear which emits a tone with a certain amount of sound energy. The probe measures how much sound energy bounces back off the eardrum, rather than being transmitted to the middle ear. The more energy that is returned to the probe, the more blocked the middle ear is.
A diagnosis of acute otitis media is based on the following:
- recent, usually abrupt, onset of signs and symptoms of middle ear inflammation and middle ear effusion
- the presence of middle ear effusion that is indicated by any of the following: bulging of the tympanic membrane; limited or absent movement of the tympanic membrane; or discharge from the external ear
- signs or symptoms of middle ear inflammation as indicated by either distinct redness of the eardrum or ear pain that results in an interference with sleep or other normal activities
Otitis media with effusion can be more difficult to detect, since it is not painful and the child usually does not appear ill. The physician may rely on one or several tests to determine the diagnosis.
- A physical examination may reveal fluid behind the eardrum and poor movement of the eardrum. The eardrum may look clear and have no signs of redness, but may not move in response to air, as a normal eardrum would.
- A tympanometry test may reveal an impairment of eardrum mobility.
- A hearing test often shows some degree of hearing loss.
Acute otitis media (AOM)
Treatment of AOM is focused on relieving any pain that may be present and addressing the infection itself. Usually, acetaminophen or ibuprofen prove adequate in relieving the pain. In cases of severe pain, narcotics may occasionally be prescribed.
Occasionally, an "observation option" will be used in a child who has uncomplicated acute otitis media. This refers to delaying antibacterial treatment of certain children for 48 to 72 hours and limiting management to symptomatic relief. The decision to observe or treat is based on the child's age, the certainty of the diagnosis, and the severity of the illness. To observe a child without initial antibacterial therapy, it is important that the parent or caregiver has a ready means of communicating with the doctor. There also must be a system in place that permits a prompt reevaluation of the child if symptoms persist or worsen. If the decision is made to use an antibiotic, the usual recommendation is for amoxicillin, preferably at a dose of 80 to 90mg/kg/day. If the initial treatment plan fails to work within 48 to 72 hours, the physician may reconsider the diagnosis of AOM. Further treatment may involve changing antibiotics .
Otitis media with effusion (OME)
For young children ages one to three years, most physicians prefer a conservative, or wait-and-see, approach, using antibiotics if the infection is persistent, the child is in pain, or there is evidence of hearing loss. Most cases of otitis media with effusion get better within three months without any treatment. If the child continues to have repeated episodes of OME, despite taking antibiotics, the physician may decide to try long-term, low-dose treatment with antibiotics, even after the condition has cleared. If OME persists for over three months, despite antibiotic treatment, the doctor may suggest a hearing test. If OME persists for more than four to six months, even if hearing tests are normal, the doctor may suggest surgery to drain the eardrum and implant ear tubes for continuous drainage.
In some cases, a surgical perforation to drain pus from the middle ear may be performed. This procedure is called a myringotomy . The hole created by the myringotomy generally heals itself in about a week. In 2002 a new minimally invasive procedure was introduced that uses a laser to perform the myringotomy. It can be performed in the doctor's office and heals more rapidly than the standard myringotomy. In some cases, the physician may decide that the placement of tubes during the myringotomy is recommended. These small tubes are placed to aid in draining the fluid from the middle ear. They fall out on their own after a few months. The decision to place these tubes is based on the following criteria:
- presence of fluid in the ears for more than three or four months following an ear infection
- fluid in the ears and more than three months of hearing loss
- changes in the structure of the eardrum as a result of ear infections
- a delay in speaking
- repeated infections that do not improve with antibiotics over several months
Another type of surgery, called an adenoidectomy, removes the adenoids. Removing the adenoids has been shown to help some children with otitis media between the ages of four to eight. It is a procedure generally reserved for those children who have recurrent otitis media after myringotomy tubes are extruded.
Treatment guidelines from the American Academy of Pediatrics and the American Academy of Family Physicians in the early 2000s state that there is insufficient evidence to either support or discourage the use of alternative medicines for acute otitis media. Increasing numbers of parents and caregivers are using various forms of nonconventional treatment for their children. Treatments that have been used for AOM include homeopathy, acupuncture, herbal remedies, chiropractic treatments, and nutritional supplements. Although most treatments are harmless, some are not. Some can have a direct and dangerous effect, whereas others may interfere with the effects of conventional treatments. Parent should inform their doctor if they are using any alternative or unconventional methods to treat their child's otitis media.
The prognosis of acute otitis media is excellent. The duration is variable. There may be improvement within 48 hours even without any treatment. Treatment with antibiotics for a week to 10 days is usually effective.
Breastfeeding helps to pass along immunities to a child that may prevent otitis media. The position the child is in while breastfeeding is better than the usual bottle-feeding position for optimal eustachian tube function. If a child must be bottle-fed, it is best to hold the infant rather than allow him or her to lie down with the bottle. Because multiple upper respiratory infections may increase the risk for acute otitis media, reducing the exposure to large groups of children, particularly in daycare centers, may reduce the incidence. Children should also be kept away from environmental irritants such as secondhand tobacco smoke.
Adenoids —Common name for the pharyngeal tonsils, which are lymph masses in the wall of the air passageway (pharynx) just behind the nose.
Effusion —The escape of fluid from blood vessels or the lymphatic system and its collection in a cavity.
Eustachian tube —A thin tube between the middle ear and the pharnyx. Its purpose is to equalize pressure on either side of the ear drum.
Myringotomy —A surgical procedure in which an incision is made in the ear drum to allow fluid or pus to escape from the middle ear.
Nasopharynx —One of the three regions of the pharynx, the nasopharynx is the region behind the nasal cavity.
Ossicles —The three small bones of the middle ear: the malleus (hammer), the incus (anvil) and the stapes (stirrup). These bones help carry sound from the eardrum to the inner ear.
A common concern among parents has been whether recurring episodes of otitis media will cause impairments in their child's development. Research indicates that persistent otitis media in the first three years of life does not have an adverse effect on development.
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American Academy of Otolaryngology—Head and Neck Surgery. One Prince Street, Alexandria, VA 22314. Web site: <www.entnet.org>.
American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007–1098. <www.aap.org>.
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Rosalyn Carson-DeWitt, MD
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"Otitis Media." Gale Encyclopedia of Children's Health: Infancy through Adolescence. . Encyclopedia.com. (February 21, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/otitis-media-0
"Otitis Media." Gale Encyclopedia of Children's Health: Infancy through Adolescence. . Retrieved February 21, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/otitis-media-0
"glue ear." A Dictionary of Nursing. . Encyclopedia.com. (February 21, 2017). http://www.encyclopedia.com/caregiving/dictionaries-thesauruses-pictures-and-press-releases/glue-ear
"glue ear." A Dictionary of Nursing. . Retrieved February 21, 2017 from Encyclopedia.com: http://www.encyclopedia.com/caregiving/dictionaries-thesauruses-pictures-and-press-releases/glue-ear