grading system for severity of AOM
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  Verify symptoms and signs: The diagnosis of acute otitis media requires the presence of symptoms, documentation of fluid in the middle ear space (middle ear effusion), and bulging of the tympanic membrane.

1. History
    Take a problem-focused history to identify symptoms, parent's perception, and risk factors.taken to identify symptoms, parent's perception of illness, and risk factors.

2. Approach to pediatric ear exam. Information on obtaining a comfortable exam.

3. Safely remove cerumen.  What to do about cerumen.

4. Middle ear effusion 

a. Link here for pneumatic otoscopy

b. Tympanometry provides an objective means of identifying a middle ear effusion (fluid in the middle ear space). Review tympanometry and practice reading tympanograms. Using tympanometry, the likelihood of a middle ear effusion is: .

Compliance > 0.2 and Gradient < 150 daPa
Middle ear effusion is unlikely.
Compliance < 0.2 and Gradient < 150 daPa
Compliance > 0.2 and Gradient  >150 daPa
65% chance of a middle ear effusion.
Compliance < 0.2 and Gradient > 150 daPa
95% chance of a middle ear effusion.

5. Appearance of the Tympanic Membrane

a. Basic anatomy

b. Practice evaluating the tympanic membrane using the pocket guide.

For more practice visit tympanic membrane exercises

The appearance of the tympanic membrane is graded for severity of disease using the 7-point scale below.  
After studying the table below showing the severity gradings (0-7) and viewing the associated tympanograms,  please visit the exercise page to practice grading the severity of AOM.


Use this pocket guite to make comparisons with your patient’s ear. Use the faces scale to assess the parents’ perception of illness severity. .
click here:



Grade 0 - Not acute otitis media
Normal appearance or effusion
without erythema.


Grade 1 - Not acute otitis media
Erythema only,
No effusion, myringitis only


Grade 2 - Not acute otitis media
Erythema, air/fluid level 
clear fluid, no opacification

Grade 3 - Not acute otitis media
Erythema, complete effusion,
no opacification

Grade 4. ?Acute otitis media?Erythema, opacification,
air fluid level or air bubble(s)
? mild bulging ?


Grade 5 ?Acute otitis media?
Erythema, complete effusion,
opacification (no bubbles)
mild bulging




Grade 6 - Acute otitis media
Erythema, bulging, rounded
doughnut appearance of tympanic membrane

Grade 7 - Acute otitis media
Erythema, bulging, bulla, complete effusion, opacification

  Please return to the exercise page.