Acute otitis media (AOM) is one of the most common diagnoses and reasons for antibiotic prescriptions in children. With more than 5 million cases diagnosed annually, it is associated with individual discomfort, family disruption, financial costs, serious sequelae, and antimicrobial resistance. For these reasons, it is important to make the correct diagnosis when evaluating the tympanic membrane (TM).

Pneumatic otoscopy allows the visualization of TM characteristics: color, contour (normal, retracted, full, bulging), position, and mobility. A normal TM is described as translucent, pearly gray, and mobile. A light reflex and boney landmarks, such as the arm of the malleus, are generally easily viewed. The examination requires that the child be restrained or held still and have patent and clear ear canal. Also, a pneumatic otoscope with a good seal and light source must be available.

• Acute onset, hyperpyrexia, and otalgia are features of AOM and not otitis media with effusion (OME).

• Concomitant or recent upper respiratory tract infections or allergies are commonly seen with AOM and OME.

• Hearing loss is a nonspecific finding that may be caused by middle ear (ME) fluid (AOM, OME), as well as by structural damage of the TM or ossicles (severe tympanosclerosis, TM perforation, or cholesteatoma).

• Refer children to a pediatric otolaryngologist whenever TM perforation is accompanied by hearing loss or vertigo, or when ME fluid is chronic and associated with hearing loss and/or speech delay.

• Suspect cholesteatoma if persistent middle ear effusion (MEE) or hearing impairment, greasy and/or whitish mass, or no clinical response is present when treating another suspected TM problem.

• When a cholesteatoma is associated with ataxia or headaches, neuroimaging should be considered to evaluate for the presence of a brain abscess.

• One must immobilize the head carefully and firmly when evaluating the TM and ear canal, while using a snug-fitting ear speculum. The small (2.5-mm diameter) ear speculum should be used in infants and preschool children, whereas the large (4-mm diameter) ear speculum should be used in school-aged children and adolescents.

• The light reflex may be absent in some normal children.

• Mobility, assessed by pneumatic otoscopy, should be measured, especially when the history and/or physical examination suggest a problem. Poor TM mobility is associated with AOM, MEE, TM perforation, or TM structural damage as with tympanosclerosis.

• Mild TM erythema can occur in association with fever, crying, upper respiratory tract infections, or irritation from cerumen or foreign objects.

• AOM should have evidence of MEE and acute inflammation, including TM bulging or fullness, marked erythema, otorrhea, or yellow or cloudy fluid.

• Air bubbles and amber TM discoloration are associated with serous ME fluid or OME.

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