In Reply.—

We thank Dr Pellman for his comments on the clinical practice guideline “Diagnosis and Management of Acute Otitis Media.” As he notes, accurate diagnosis is the key to appropriate management of this common condition. The debate as to the place of bulging in the diagnosis of acute otitis media (AOM) is important, and many commentators have stated that significant bulging is the most reliable sign of AOM.

Issues related to the articles by Halsted et al and Schwartz et al, as well as the studies by Karma et al that served as the basis for Pelton's review, have been addressed previously in a letter to the editor of Pediatrics and its reply. To summarize, each of the quoted studies has flaws that result in the true relationship of bulging in the diagnosis of AOM being inconclusive. A well-conducted study to...

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