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==Overview==
The mainstay of therapy for acute otitis media (AOM) is antimicrobial therapy. High-dose [[Amoxicillin]] is the drug of choice for initial antibiotic therapy; high-dose [[Amoxicillin-Clavulanate]] or [[intramuscular]] [[Ceftriaxone]] should be reserved for patients who fail to respond to first-line treatment within 48 to 72 hours. Antimicrobial agents covering common bacterial pathogens (e.g., ''[[Streptococcus pneumoniae]]'', ''[[Moraxella catarrhalis]]'', and non-typeable ''[[Haemophilus influenzae]]'') have been used with success in selected patients to accelerate the recovery and lower the risk of [[tympanic membrane perforation]]s and contralateral AOM episodes.<ref>{{Cite journal| doi = 10.1002/14651858.CD000219.pub3| issn = 1469-493X| volume = 1| pages = –000219| last1 = Venekamp| first1 = Roderick P.| last2 = Sanders| first2 = Sharon| last3 = Glasziou| first3 = Paul P.| last4 = Del Mar| first4 = Chris B.| last5 = Rovers| first5 = Maroeska M.| title = Antibiotics for acute otitis media in children| journal = The Cochrane Database of Systematic Reviews| date = 2013| pmid = 23440776}}</ref>  The optimal duration of antibiotics remains uncertain: a 10-day course of antibiotic therapy is recommended for children younger than 2 years and children with severe symptoms. In the absence of severe symptoms, a 7- or 5-day course is advisable for children 2 to 5 years of age or children 6 years and older, respectively. Current guidelines recommend observation for children age 6 to 24 months with unilateral AOM without [[otorrhea]] or children older than 2 years with unilateral or bilateral AOM without [[otorrhea]].<ref>{{Cite journal| doi = 10.1136/archdischild-2013-305550| issn = 1743-0593| last1 = Siddiq| first1 = Somiah| last2 = Grainger| first2 = Joe| last3 = Prentice| first3 = Philippa| title = The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013| journal = Archives of Disease in Childhood. Education and Practice Edition| date = 2014-11-12| pmid = 25395494}}</ref> [[Otalgia]] is generally managed with [[Acetaminophen]], [[Ibuprofen]], or [[narcotic]] [[analgesic]]s with [[Codeine]].<ref>{{Cite journal| doi = 10.1136/archdischild-2013-305550| issn = 1743-0593| last1 = Siddiq| first1 = Somiah| last2 = Grainger| first2 = Joe| last3 = Prentice| first3 = Philippa| title = The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013| journal = Archives of Disease in Childhood. Education and Practice Edition| date = 2014-11-12| pmid = 25395494}}</ref>


==Medical Therapy==
==Medical Therapy==
===Acute Otitis Media===
===Initial Management of Uncomplicated Acute Otitis Media with High Certainty of Diagnosis===
Treatment of acute otitis media is controversial. Much of the controversy centers around the difficulty of distinguishing [[viral]] infection from [[bacterial]] infection and the fact that viral infection can progress to bacterial infection at any time. Primary care providers, such as general practitioners and pediatricians, often have a monocular [[otoscope]] and perhaps a [[tympanometer]] as their only diagnostic tools, which makes this distinction difficult, especially if the canal is small and there is wax in the ear that obscures a clear view of the eardrum. Also, an upset child's crying can cause the eardrum to look inflamed due to causing distention of the small blood vessels on it, mimicking the redness associated with otitis media.  Because of a tradition of inappropriate prescribing of [[antibiotic]]s for viral acute otitis media, their use has recently been condemned by many primary care practitioners for most cases of acute otitis media. Ear specialists tend to disagree with this philosophy and promote efforts to distinguish between viral and bacterial infection, so as to optimize treatment results by giving [[antibiotic]]s only for bacterial infection. Acute bacterial otitis media can cause pain that leads to sleepless nights for both children and parents, can cause eardrum perforations, not all of which heal, and can spread to cause mastoiditis and/or meningitis, brain abscess, and even death if a severe infection goes untreated long enough. High fever can occur and can cause febrile seizures.  Appropriate antibiotic administration prevents most such complications. On the other hand, it is generally agreed that acute otitis media that is purely viral will usually resolve without antibiotic treatment, although associated persistent middle ear effusions may require medical intervention.<ref>{{cite journal | author = Damoiseaux R, van Balen F, Hoes A, Verheij T, de Melker R | title = Primary care based randomised, double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years. | journal = BMJ | volume = 320 | issue = 7231 | pages = 350-4 | year = 2000 | id = PMID 10657332}}</ref><ref>{{cite journal | author = Arroll B | title = Antibiotics for upper respiratory tract infections: an overview of Cochrane reviews. | journal = Respir Med | volume = 99 | issue = 3 | pages = 255-61 | year = 2005 | id = PMID 15733498}}</ref><ref>{{cite journal | author = Rovers MM, Glasziou P, Appelman CL, Burke P, McCormick DP, Damoiseaux RA, Gaboury I, Little P, Hoes AW. | title = Antibiotics for acute otitis media: a meta-analysis with individual patient data. | journal = Lancet. | volume = 368 | issue = 9545 | pages = 1429-35 | year = 2006 | id = PMID 17055944}}</ref>
 
{| style="font-size: 85%;"
|+ '''Clinical Practice Guideline from the American Academy of Pediatrics'''<ref>{{Cite journal| doi = 10.1136/archdischild-2013-305550| issn = 1743-0593| last1 = Siddiq| first1 = Somiah| last2 = Grainger| first2 = Joe| last3 = Prentice| first3 = Philippa| title = The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013| journal = Archives of Disease in Childhood. Education and Practice Edition| date = 2014-11-12| pmid = 25395494}}</ref>
| style="padding: 2px 10px; background: #4479BA; color: #FFFFFF;" | Age
| style="padding: 2px 10px; background: #4479BA; color: #FFFFFF;" | AOM With Otorrhea
| style="padding: 2px 10px; background: #4479BA; color: #FFFFFF;" | AOM With Severe Symptoms<sup>†</sup>
| style="padding: 2px 10px; background: #4479BA; color: #FFFFFF;" | Bilateral AOM Without Otorrhea
| style="padding: 2px 10px; background: #4479BA; color: #FFFFFF;" | Unilateral AOM Without Otorrhea
|-
| style="padding: 2px 10px; background: #DCDCDC;" | 6 months to 2 years old
| style="padding: 2px 10px; background: #F5F5F5;" | Antibiotic therapy
| style="padding: 2px 10px; background: #F5F5F5;" | Antibiotic therapy
| style="padding: 2px 10px; background: #F5F5F5;" | Antibiotic therapy
| style="padding: 2px 10px; background: #F5F5F5;" | Antibiotic therapy or additional observation
|-
| style="padding: 2px 10px; background: #DCDCDC;" | ≥ 2 years old
| style="padding: 2px 10px; background: #F5F5F5;" | Antibiotic therapy
| style="padding: 2px 10px; background: #F5F5F5;" | Antibiotic therapy
| style="padding: 2px 10px; background: #F5F5F5;" | Antibiotic therapy or additional observation
| style="padding: 2px 10px; background: #F5F5F5;" | Antibiotic therapy or additional observation
|}
<SMALL><sup>†</sup> A toxic-appearing child, persistent otalgia more than 48 h, temperature ≥39°C (102.2°F) in the past 48 h, or if there is uncertain access to follow-up after the visit.</SMALL>
 
===Rationale for Antibiotic Therapy Choice===
The rationale for antibiotic therapy in children with AOM is based on a high prevalence of bacteria from [[tympanocentesis]] cultures.  A significant benefit of immediate antibiotic therapy is most evident in bilateral AOM, AOM with severe symptotms, AOM with [[otorrhea]], or ''[[Streptococcus pneumoniae]]'' infection.<ref>{{Cite journal| doi = 10.1016/S0140-6736(06)69606-2| issn = 1474-547X| volume = 368| issue = 9545| pages = 1429–1435| last1 = Rovers| first1 = Maroeska M.| last2 = Glasziou| first2 = Paul| last3 = Appelman| first3 = Cees L.| last4 = Burke| first4 = Peter| last5 = McCormick| first5 = David P.| last6 = Damoiseaux| first6 = Roger A.| last7 = Gaboury| first7 = Isabelle| last8 = Little| first8 = Paul| last9 = Hoes| first9 = Arno W.| title = Antibiotics for acute otitis media: a meta-analysis with individual patient data| journal = Lancet| date = 2006-10-21| pmid = 17055944}}</ref> Antibiotic therapy is recommended in the following settings:
* AOM (bilateral or unilateral) in children 6 months and older with '''severe signs or symptoms''' (i.e., moderate or severe otalgia or otalgia for at least 48 hours, or temperature 39°C [102.2°F] or higher)
* '''Bilateral''' AOM in children younger than 24 months without severe signs or symptoms
 
When a decision to treat with antibiotics has been made, high-dose [[amoxicillin]] is recommended if all of the following criteria are fulfilled:<ref>{{Cite journal| doi = 10.1542/peds.2012-3488| issn = 1098-4275| volume = 131| issue = 3| pages = –964-999| last1 = Lieberthal| first1 = Allan S.| last2 = Carroll| first2 = Aaron E.| last3 = Chonmaitree| first3 = Tasnee| last4 = Ganiats| first4 = Theodore G.| last5 = Hoberman| first5 = Alejandro| last6 = Jackson| first6 = Mary Anne| last7 = Joffe| first7 = Mark D.| last8 = Miller| first8 = Donald T.| last9 = Rosenfeld| first9 = Richard M.| last10 = Sevilla| first10 = Xavier D.| last11 = Schwartz| first11 = Richard H.| last12 = Thomas| first12 = Pauline A.| last13 = Tunkel| first13 = David E.| title = The diagnosis and management of acute otitis media| journal = Pediatrics| date = 2013-03| pmid = 23439909}}</ref>
*The patient has not received [[amoxicillin]] in the past 30 days.
*The patient does not have concurrent purulent [[conjunctivitis]].
*The patient is not allergic to [[penicillin]].
 
Additional [[Beta-lactamase|β-lactamase]] coverage should be considered if any of the following criteria is fulfilled:<ref>{{Cite journal| doi = 10.1542/peds.2012-3488| issn = 1098-4275| volume = 131| issue = 3| pages = –964-999| last1 = Lieberthal| first1 = Allan S.| last2 = Carroll| first2 = Aaron E.| last3 = Chonmaitree| first3 = Tasnee| last4 = Ganiats| first4 = Theodore G.| last5 = Hoberman| first5 = Alejandro| last6 = Jackson| first6 = Mary Anne| last7 = Joffe| first7 = Mark D.| last8 = Miller| first8 = Donald T.| last9 = Rosenfeld| first9 = Richard M.| last10 = Sevilla| first10 = Xavier D.| last11 = Schwartz| first11 = Richard H.| last12 = Thomas| first12 = Pauline A.| last13 = Tunkel| first13 = David E.| title = The diagnosis and management of acute otitis media| journal = Pediatrics| date = 2013-03| pmid = 23439909}}</ref>
*The patient has received [[amoxicillin]] in the past 30 days.
*The patient has concurrent [[purulent]] [[conjunctivitis]].
*The patient has a history of recurrent AOM unresponsive to [[amoxicillin]].
 
===Duration of Therapy===
*Standard 10-day course of antibiotic therapy is recommended for children younger than 2 years and children with severe symptoms. 
*In the absence of severe symptoms, a 7- or 5-day course is advisable for children 2 to 5 years of age or children 6 years and older, respectively.


Many guidelines now suggest deferring the start of antibiotics for one to three days<ref>{{cite journal | author = Damoiseaux R | title = Antibiotic treatment for acute otitis media: time to think again. | journal = CMAJ | volume = 172 | issue = 5 | pages = 657-8 | year = 2005 | id = PMID 15738492}}</ref> avoiding the need for antibiotics for two out of three children<ref>{{cite journal | author = Marchetti F, Ronfani L, Nibali S, Tamburlini G | title = Delayed prescription may reduce the use of antibiotics for acute otitis media: a prospective observational study in primary care. | journal = Arch Pediatr Adolesc Med | volume = 159 | issue = 7 | pages = 679-84 | year = 2005 | id = PMID 15997003}}</ref> without adverse effect on longterm outcomes for those whose treatment is deferred.<ref>{{cite journal | author = Little P, Moore M, Warner G, Dunleavy J, Williamson I | title = Longer term outcomes from a randomised trial of prescribing strategies in otitis media. | journal = Br J Gen Pract | volume = 56 | issue = 524 | pages = 176-82 | year = 2006 | id = PMID 16536957}}</ref> First line antibiotic treatment, if warranted, is [[amoxicillin]]. If the [[bacteria]] is resistant, then [[co-amoxiclav|amoxicillin-clavulanate]] or another [[penicillin]] derivative plus beta lactamase inhibitor is used.
===Antibiotic Regimens===
===Chronic Otitis Media with Effusion===
====Initial (Immediate or Delayed) Antibiotic Treatment====
In chronic cases or with effusions present for months, surgery is sometimes performed. It is possible to use the [[Valsalva maneuver]] to reestablish middle ear ventilation, although repeated use of the [[Valsalva maneuver]] can cause infected matter to enter the eye cavity and cause [[conjunctivitis]].
*Preferred Regimen
===Alternative Therapies===
**[[Amoxicillin]] 80–90 mg/kg/d bid {{or}} [[Amoxicillin]] 90 mg/kg/d with [[Clavulanate]] 6.4 mg/kg/d
Alternatives to conventional medical approaches include [[chiropractic]] and [[Osteopathic medicine in the United States|osteopathic]] spinal manipulations, targeted to relieve muscle tension to enhance lymphatic flow and allow normal opening of the [[Eustachian tube]]. Such alternatives are becoming increasingly widely used. Otitis Media has also been found to respond to [[homeopathic]] remedies.<ref>{{cite book | title = Childhood Ear Infections: A Parent's Guide to Alternative Treatments | author = Michael A. Schmidt |publisher = North Atlantic Books | year = 2003 | isbn = 1556434421 }} [http://books.google.com/books?id=7DPwoHjD_bAC&pg=PA147&dq=osteopathy+%22otitis+media%22+chiropractic&lr=&as_brr=0&ei=7UrKR8TDLILusgO_r_XBAw&sig=rNkOdI8AQJiSex76-Kjaakj0i_8] [http://books.google.com/books?id=nGjDjqaz-fAC&pg=PA120&dq=homeopathy+%22otitis+media%22&lr=&as_brr=0&ei=7kzKR6qxEoOotgOd4aHBAw&sig=KX0P1K64Ky0mm6GvY8kBrj5joqw#PPA119,M1 ]</ref> Eardoc treatment reduces the fluids in the middle ear by opening the [[Eustachian tube]]. Its efficiency can be viewed and tested  with a [[tympanometer]].
*Alternative Regimen (if allergic to [[penicillin]])
**[[Cefdinir]] 14 mg/kg/d qd or bid {{or}} [[Cefuroxime]] 30 mg/kg/d bid {{or}} [[Cefpodoxime]] 10 mg/kg/d bid {{or}} [[Ceftriaxone]] 50 mg/kg IM/IV qd
 
====After Failure of Initial Antibiotic Treatment====
*Preferred Regimen
**[[Amoxicillin]] 90 mg/kg/d with [[Clavulanate]] 6.4 mg/kg/d {{or}} [[Ceftriaxone]] 50 mg/kg IM/IV qd
*Alternative Regimen
**[[Clindamycin]] 30–40 mg/kg/d tid ± 3° [[Cephalosporin]] ± [[Tympanocentesis]]
 
===Pain Management===
Episodes of AOM are commonly associated with [[otalgia]], managed by the following: 
*[[Acetaminophen]]
*[[Ibuprofen]]
*[[Codeine]]
**Should be used with caution in the treatment of severe [[otalgia]] due to the risk of [[respiratory depression]], [[altered mental status]], [[abdominal pain|gastrointestinal upset]], and [[constipation]]. <ref>{{Cite journal| doi = 10.1542/peds.2012-3488| issn = 1098-4275| volume = 131| issue = 3| pages = –964-999| last1 = Lieberthal| first1 = Allan S.| last2 = Carroll| first2 = Aaron E.| last3 = Chonmaitree| first3 = Tasnee| last4 = Ganiats| first4 = Theodore G.| last5 = Hoberman| first5 = Alejandro| last6 = Jackson| first6 = Mary Anne| last7 = Joffe| first7 = Mark D.| last8 = Miller| first8 = Donald T.| last9 = Rosenfeld| first9 = Richard M.| last10 = Sevilla| first10 = Xavier D.| last11 = Schwartz| first11 = Richard H.| last12 = Thomas| first12 = Pauline A.| last13 = Tunkel| first13 = David E.| title = The diagnosis and management of acute otitis media| journal = Pediatrics| date = 2013-03| pmid = 23439909}}</ref>
 
===Antimicrobial regimens===
*'''Acute otitis media''' <ref name="pmid23439909">{{cite journal| author=Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA et al.| title=The diagnosis and management of acute otitis media. | journal=Pediatrics | year= 2013 | volume= 131 | issue= 3 | pages= e964-99 | pmid=23439909 | doi=10.1542/peds.2012-3488 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439909  }} </ref>
:*'''1. Causative pathogens'''
::*Streptococcus pneumoniae
::*Hemophilus influenzae
::*Moraxella catarrhalis
::*Polymicrobial
::*Viral
:*'''2. Empiric antimicrobial therapy'''
::*Preferred regimen: [[Amoxicillin]] 40–90 mg/kg/day PO q12h {{or}} [[Amoxicillin-Clavulanate]] 90/6.4 mg/kg/day PO q12h
::*Alternative regimen: [[Cefdinir]] 14 mg/kg/day PO q12 or q24h {{or}} [[Cefuroxime]] 30 mg/kg/day PO q12h {{or}} [[Cefpodoxime]] 10 mg/kg/day PO q12h {{or}} [[Ceftriaxone]] 50 mg/kg/day IM or IV q24h
::*Note: [[Amoxicillin-Clavulanate]] may be considered in patients with recent [[Amoxicillin]] intake or concomitant conjunctivitis. Alternative regimens should be considered in patients with [[Penicillin]] allergies. Re-evaluate after 2-3 days for treatment response.
:*'''3. Special considerations'''
::*'''3.1 Acute otitis media post-treatment failure (48-72 hours)'''
:::*Preferred regimen: [[Amoxicillin-Clavulanate]] 90/6.4 mg/kg/day PO q12h {{or}} [[Ceftriaxone]] 50 mg/kg/day IM or IV q24h
:::*Alternative regimen: [[Clindamycin]] 30–40 mg/kg/day PO q8h '''±''' ([[Cefdinir]] 14 mg/kg/day PO q12 or q24h {{or}} [[Cefuroxime]] 30 mg/kg/day PO q12h {{or}} [[Cefpodoxime]] 10 mg/kg/day PO q12h {{or}} [[Ceftriaxone]] 50 mg/kg/day IM or IV q24h)
::*'''3.2 Acute otitis media post-intubation'''<ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
:::*Preferred regimen: [[Ceftazidime]] 2 g IV q8h {{or}} [[Cefepime]] 2 g IV q12h {{or}} [[Imipenem]] 0.5 g IV q6h {{or}} [[Meropenem]] 500 mg IV q8h {{or}} [[Piperacillin-Tazobactam]] 4–6 g IV q4–6h {{or}} [[Ticarcillin-Clavulanate]] 3 g IV q4h {{or}} [[Ciprofloxacin]] 400 mg IV q12h {{or}} [[Ciprofloxacin]] 750 mg PO q12h


==References==
==References==
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maliha Shakil, M.D. [2]; Shanshan Cen, M.D. [3]; Mohamed Moubarak, M.D. [4]; Luke Rusowicz-Orazem, B.S.

Overview

The mainstay of therapy for acute otitis media (AOM) is antimicrobial therapy. High-dose Amoxicillin is the drug of choice for initial antibiotic therapy; high-dose Amoxicillin-Clavulanate or intramuscular Ceftriaxone should be reserved for patients who fail to respond to first-line treatment within 48 to 72 hours. Antimicrobial agents covering common bacterial pathogens (e.g., Streptococcus pneumoniae, Moraxella catarrhalis, and non-typeable Haemophilus influenzae) have been used with success in selected patients to accelerate the recovery and lower the risk of tympanic membrane perforations and contralateral AOM episodes.[1] The optimal duration of antibiotics remains uncertain: a 10-day course of antibiotic therapy is recommended for children younger than 2 years and children with severe symptoms. In the absence of severe symptoms, a 7- or 5-day course is advisable for children 2 to 5 years of age or children 6 years and older, respectively. Current guidelines recommend observation for children age 6 to 24 months with unilateral AOM without otorrhea or children older than 2 years with unilateral or bilateral AOM without otorrhea.[2] Otalgia is generally managed with Acetaminophen, Ibuprofen, or narcotic analgesics with Codeine.[3]

Medical Therapy

Initial Management of Uncomplicated Acute Otitis Media with High Certainty of Diagnosis

Clinical Practice Guideline from the American Academy of Pediatrics[4]
Age AOM With Otorrhea AOM With Severe Symptoms Bilateral AOM Without Otorrhea Unilateral AOM Without Otorrhea
6 months to 2 years old Antibiotic therapy Antibiotic therapy Antibiotic therapy Antibiotic therapy or additional observation
≥ 2 years old Antibiotic therapy Antibiotic therapy Antibiotic therapy or additional observation Antibiotic therapy or additional observation

A toxic-appearing child, persistent otalgia more than 48 h, temperature ≥39°C (102.2°F) in the past 48 h, or if there is uncertain access to follow-up after the visit.

Rationale for Antibiotic Therapy Choice

The rationale for antibiotic therapy in children with AOM is based on a high prevalence of bacteria from tympanocentesis cultures. A significant benefit of immediate antibiotic therapy is most evident in bilateral AOM, AOM with severe symptotms, AOM with otorrhea, or Streptococcus pneumoniae infection.[5] Antibiotic therapy is recommended in the following settings:

  • AOM (bilateral or unilateral) in children 6 months and older with severe signs or symptoms (i.e., moderate or severe otalgia or otalgia for at least 48 hours, or temperature 39°C [102.2°F] or higher)
  • Bilateral AOM in children younger than 24 months without severe signs or symptoms

When a decision to treat with antibiotics has been made, high-dose amoxicillin is recommended if all of the following criteria are fulfilled:[6]

Additional β-lactamase coverage should be considered if any of the following criteria is fulfilled:[7]

Duration of Therapy

  • Standard 10-day course of antibiotic therapy is recommended for children younger than 2 years and children with severe symptoms.
  • In the absence of severe symptoms, a 7- or 5-day course is advisable for children 2 to 5 years of age or children 6 years and older, respectively.

Antibiotic Regimens

Initial (Immediate or Delayed) Antibiotic Treatment

After Failure of Initial Antibiotic Treatment

Pain Management

Episodes of AOM are commonly associated with otalgia, managed by the following:

Antimicrobial regimens

  • Acute otitis media [9]
  • 1. Causative pathogens
  • Streptococcus pneumoniae
  • Hemophilus influenzae
  • Moraxella catarrhalis
  • Polymicrobial
  • Viral
  • 2. Empiric antimicrobial therapy
  • 3. Special considerations
  • 3.1 Acute otitis media post-treatment failure (48-72 hours)
  • 3.2 Acute otitis media post-intubation[10]

References

  1. Venekamp, Roderick P.; Sanders, Sharon; Glasziou, Paul P.; Del Mar, Chris B.; Rovers, Maroeska M. (2013). "Antibiotics for acute otitis media in children". The Cochrane Database of Systematic Reviews. 1: –000219. doi:10.1002/14651858.CD000219.pub3. ISSN 1469-493X. PMID 23440776.
  2. Siddiq, Somiah; Grainger, Joe; Prentice, Philippa (2014-11-12). "The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013". Archives of Disease in Childhood. Education and Practice Edition. doi:10.1136/archdischild-2013-305550. ISSN 1743-0593. PMID 25395494.
  3. Siddiq, Somiah; Grainger, Joe; Prentice, Philippa (2014-11-12). "The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013". Archives of Disease in Childhood. Education and Practice Edition. doi:10.1136/archdischild-2013-305550. ISSN 1743-0593. PMID 25395494.
  4. Siddiq, Somiah; Grainger, Joe; Prentice, Philippa (2014-11-12). "The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013". Archives of Disease in Childhood. Education and Practice Edition. doi:10.1136/archdischild-2013-305550. ISSN 1743-0593. PMID 25395494.
  5. Rovers, Maroeska M.; Glasziou, Paul; Appelman, Cees L.; Burke, Peter; McCormick, David P.; Damoiseaux, Roger A.; Gaboury, Isabelle; Little, Paul; Hoes, Arno W. (2006-10-21). "Antibiotics for acute otitis media: a meta-analysis with individual patient data". Lancet. 368 (9545): 1429–1435. doi:10.1016/S0140-6736(06)69606-2. ISSN 1474-547X. PMID 17055944.
  6. Lieberthal, Allan S.; Carroll, Aaron E.; Chonmaitree, Tasnee; Ganiats, Theodore G.; Hoberman, Alejandro; Jackson, Mary Anne; Joffe, Mark D.; Miller, Donald T.; Rosenfeld, Richard M.; Sevilla, Xavier D.; Schwartz, Richard H.; Thomas, Pauline A.; Tunkel, David E. (2013-03). "The diagnosis and management of acute otitis media". Pediatrics. 131 (3): –964-999. doi:10.1542/peds.2012-3488. ISSN 1098-4275. PMID 23439909. Check date values in: |date= (help)
  7. Lieberthal, Allan S.; Carroll, Aaron E.; Chonmaitree, Tasnee; Ganiats, Theodore G.; Hoberman, Alejandro; Jackson, Mary Anne; Joffe, Mark D.; Miller, Donald T.; Rosenfeld, Richard M.; Sevilla, Xavier D.; Schwartz, Richard H.; Thomas, Pauline A.; Tunkel, David E. (2013-03). "The diagnosis and management of acute otitis media". Pediatrics. 131 (3): –964-999. doi:10.1542/peds.2012-3488. ISSN 1098-4275. PMID 23439909. Check date values in: |date= (help)
  8. Lieberthal, Allan S.; Carroll, Aaron E.; Chonmaitree, Tasnee; Ganiats, Theodore G.; Hoberman, Alejandro; Jackson, Mary Anne; Joffe, Mark D.; Miller, Donald T.; Rosenfeld, Richard M.; Sevilla, Xavier D.; Schwartz, Richard H.; Thomas, Pauline A.; Tunkel, David E. (2013-03). "The diagnosis and management of acute otitis media". Pediatrics. 131 (3): –964-999. doi:10.1542/peds.2012-3488. ISSN 1098-4275. PMID 23439909. Check date values in: |date= (help)
  9. Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA; et al. (2013). "The diagnosis and management of acute otitis media". Pediatrics. 131 (3): e964–99. doi:10.1542/peds.2012-3488. PMID 23439909.
  10. Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.