In which situation should patients with acute otitis media be referred to a specialist?

Patients with acute otitis media should be referred to a specialist in any of the situations described, making the comprehensive choice that includes all these scenarios the best one.

When patients experience concurrent vertigo or ataxia, it suggests that the infection may be affecting other structures in the ear, potentially indicating a more serious condition that requires evaluation by an otolaryngologist. This could mean involvement of the vestibular system or other complications that should be addressed immediately.

A failed closure of a ruptured tympanic membrane is another critical reason for referral. If the tympanic membrane does not heal properly, there is a risk of persistent middle ear problems, which can lead to chronic otitis media or even hearing loss, necessitating further intervention.

Lastly, if symptoms worsen after 3 or 4 days of treatment, particularly when there is a diagnosed bacterial infection, this could indicate resistance to treatment, the presence of complications, or an alternative diagnosis. In such cases, a specialist can provide more specialized care and consider options such as additional imaging or surgical interventions if necessary.

Each of these situations highlights the need for a specialist’s expertise to prevent complications and ensure effective management of the patient's condition. Thus, referral is warranted in all the described cases.