The child may present with crying, irritability, and restless sleep. These may be the only signs in an infant, or the infant may rub or pull at the ear. Older children will complain of pain, dizziness, and headache. Fever in infants may be very high, or it may be absent. Symptoms of an upper respiratory tract infection are usually present. Vomiting or diarrhea, or both, may be prominent. The symptoms of AOM involving anaerobes are similar to those found in infections caused by aerobes and facultatives. Examination of the ear may reveal distortion or absence of clear landmarks and light reflex, impaired drum mobility, opaqueness, thickening, flaming and diffusely red drum rather than the normal pearl-gray, and the drum may bulge. If the tympanic membrane has ruptured, an opening may be seen as discharging pus or serous fluid. A foul-smelling exudate or pus is associated with the presence of anaerobic bacteria.

A conductive-type hearing loss is always present. It should be noted that mild redness of the drum in the presence of high fever is often entirely nonspecific and is related only to the fever. Hyperemia of the drum may occur with crying.

Under certain circumstances, tympanocentesis or myringotomy should be performed (21). Indications for tympanocentesis include failure to respond to antimicrobial therapy, neonatal age, the presence of severe symptoms including severe otalgia or high fever, and suppurative complications. This procedure could be beneficial for some patients for whom the determination of the etiology of the AOM and the antimicrobial sensitivity of the organism(s), drainage of pus, and relief of pain and acute symptoms is important. Bacterial cultures for aerobic and anaerobic bacteria should be obtained. A simplified technique, using a modified Medicut*, can prevent gross contamination of the specimen (22).

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