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Acute otitis media (AOM) can be difficult to diagnose in a crying child. The vessels of the ear canal and tympanic membrane (TM) can engorge simulating AOM. We observed the pattern of vascular congestion during modified Valsalva maneuver. Sparing of the pars tensa, lack of TM bulging help to differentiate a crying child’s red TM from that seen in AOM.