Acute otitis media may be defined as the sudden onset of inflammation in the middle-ear space characterized by ear pain and a bulging, thickened, and immobile tympanic membrane. The middle-ear fluid is typically purulent. A bacterial pathogen is recovered in 75% of the episodes. Streptococcus pneumoniae predominates at 35%, followed by nontypeable Hemophilus influenzae at 25%, and Moraxella catarrhalis at 15%. The remaining 25% of middle-ear fluids are sterile and presumably represent viral infections. Increasing evidence suggests that viruses may participate in more than 50% of all acute otitis media (AOM) episodes; however, pure viral AOM is relatively uncommon. IThe natural course of AOM has not been studied in the past decade. A review of articles concerning treatment of AOM demonstrates a spontaneous self-resolution rate between 30 and 80%.24 This rate varies with the specific pathogen from a high rate of 79% with M. catarrhalis to a low rate of 11% with S. pne~moniae.'.~ The mechanisms of eradication appear to involve various host defenses, including phagocytosis and destruction within neutrophils, lysis by host products outside of the cell, immunologic destruction by antibody and complement, and drainage of pus from the middle-ear space through the eustachian tube.Ample evidence has been accumulated that supports the role of serum antibody in protecting the middle-ear space from infection. For example, the incidence of AOM is relatively low during the first six months of life when maternally acquired antibody levels are relatively high in infants. More specifically, antibody concentrations to S. pneumoniae in cord blood correlate to susceptibility to the development of pneumococcal otitis media, as does the level of antibody to nontypeable H. influenzae in older Low levels of antibody can be corrected by passive immunization with serum containing high titers of antibody. By passively raising levels of pneumococcal antibody, the frequency of otitis media is reduced. I* Active immunization with S. pneumoniae has also been associated with a reduced frequency of