Tintinalli's Emergency Medicine - Just the Facts, 3ed.


David M. Spiro



images Acute otitis media (AOM) accounts for 13% of emergency departments visits.

images The incidence is higher in males, children who attend day care, children exposed to smoke, and those with a family history of AOM.

images The most common pathogens are Streptococcus pneu-moniae (31%) and non-typeable Haemophilus influ-enzae (56%).


images Abnormal function of the eustachian tube appears to be the dominant factor in the pathogenesis of middle ear disease.


images The peak age is 6 to 36 months.

images Symptoms include fever, poor feeding, irritability, vomiting, otalgia, and otorrhea.

images Signs include bulging pus behind the tympanic membrane (TM) (Fig. 70-1), an immobile TM, loss of visualization of bony landmarks within the middle ear, and bullae on the TM (bullous myringitis).


FIG. 70–1. Acute otitis media in a 3-year-old child with an outward bulge of the tympanic membrane and an exudative process in the middle ear space. (Courtesy of Dr. Shelagh Cofer, Department of Otolaryngology, Mayo Clinic.)


images Making an accurate diagnosis is the most important first step.

images The definition of acute otitis media requires (A) acute onset (<48 hours) of signs and symptoms, (B) middle ear effusion (Fig. 70-1), and (C) signs and symptoms of middle ear inflammation. A red TM alone does not indicate the presence of an ear infection. Fever, prolonged crying, and viral infections can cause hyperemia of the TM. The normal TM is translucent and pearly grey (see Fig. 70-2).

images The most common causes of acute otalgia include AOM, otitis media with effusion, foreign body in the external ear canal, and otitis externa.


FIG. 70–2. Normal right tympanic membrane in 6-year-old child. (Courtesy of Dr. Shelagh Cofer, Department of Otolaryngology, Mayo Clinic.)


images Treatment of pain is essential for all children diagnosed with AOM. Topical analgesics such as benzo-caine-antipyrene are recommended for routine use, unless there is a known perforation of the TM. Ibuprofen 10 milligrams/kg/dose is the preferred oral analgesic for AOM.

images Consider use of a “wait-and-see” prescription for the treatment of uncomplicated AOM. Parents are given a prescription and told to wait and see for 48 hours, and if the child is not better to fill the prescription. Treat AOM with immediate antibiotics with any of the following: age <6 months, an immunocompromised state, ill-appearance, recent use of antibiotics, or the diagnosis of another bacterial infection.

images Amoxicillin 40 to 50 milligrams/kg/dose PO twice daily remains the first drug of choice for uncomplicated AOM.

images Second-line antibiotics include amoxicillin/cla-vulanate 40 to 50 milligrams/kg/dose twice daily, cefpodoxime 5 milligrams/kg/dose PO twice daily, cefuroxime axetil 15 milligrams/kg/dose PO twice daily, cefdinir 7 milligrams/kg/dose PO twice daily, and ceftriaxone 50 milligrams/kg/d IM for three doses are alternatives. For patients allergic to the previously mentioned antibiotics, azithromycin 10 milligrams/kg/single dose PO on the first day followed by 5 milligrams/kg/single dose PO for 4 more days can be used.

images Infants less than 30 days of age with AOM are at risk for infection with group B Streptococcus, Staphylococcus aureus, and gram-negative bacilli and should undergo evaluation and treatment for presumed sepsis.

images In uncomplicated AOM, symptoms resolve within 48 to 72 hours; however, the middle ear effusion may persist as long as 8 to 12 weeks. Routine follow-up is not necessary unless the symptoms persist or worsen.

images Mastoiditis is the most common, serious complication of AOM. If mastoiditis is suspected, obtain a CT scan of the mastoid. If the diagnosis is confirmed, obtain consultation with an otolaryngologist and start IV antibiotics.



images Otitis externa (OE) is an inflammatory process involving the auricle, external auditory canal (EAC), and surface of the TM. It is commonly caused by Pseudomonas aeruginosa, Staphylococcus epider-midis, and Staph. aureus, which often coexist.


images OE occurs when protective features are compromised, often due to hyperhydration and maceration of the epithelial tissue, such as when a child is submerged during swimming.


images Peak seasons for OE are spring and summer, and the peak age is 9 to 19 years.

images Symptoms include earache, itching, and fever.

images Signs include erythema, edema of the EAC, white exudate in the EAC, pain with motion of tragus or auricle, and periauricular or cervical adenopathy.


images Diagnosis of OE is based on clinical signs and symptoms. A foreign body within the external canal should be excluded by carefully removing any debris that may be present.


images Cleaning the ear canal with a small tuft of cotton attached to a wire applicator is the first step. Place a wick in the canal if significant edema obstructs the EAC.

images Mild OE may be treated with acidifying agents alone, such as 2% acetic acid.

images Consider oral analgesics, such as ibuprofen at 10 milligrams/kg/dose every 6 hours as needed.

images Fluoroquinolone otic drops are now considered the preferred agents over neomycin-containing drops. Ciprofloxacin with hydrocortisone, 0.2% and 1% suspension (Cipro HC), three drops twice daily or ofloxacin 0.3% solution 10 drops twice daily can be used. Ofloxacin is used when TM rupture is found or suspected.

images Oral antibiotics are indicated if auricular cellulitis is present.

images Follow-up should be advised if improvement does not occur within 48 hours; otherwise routine follow-up is not recommended.



images Sinusitis is an inflammatory process that may be secondary to infection or allergy and may be acute, subacute, or chronic.

images Approxiamately 8% of upper respiratory infections (URIs) develop into acute sinusitis.


images Blockage of the ostia by mucous and inflammation predisposes to acute sinusitis.

images The major pathogens in childhood are Strep. pneu-moniae, Moraxella catarrhalis, and nontypeable H. influenzae.


images Acute sinusitis is associated with persistant (nasal drainage for 10–30 days) and severe symptoms (fever >39°C, purulent drainage, headaches, and localized swelling and tenderness or erythema over the sinuses).

images Reproducible, unilateral tenderness to percussion or direct pressure over the frontal or maxillary sinuses may indicate acute infection.


images The diagnosis is made on clinical grounds without routine use of imaging studies.

images Nasal congestion or colored drainage from the nose lasting up to 7 days often indicates a viral URI and should not be diagnosed as acute sinusitis and does not need treatment with antibiotics.


images For children with mild to moderate sinusitis, treat with high-dose amoxicillin (40–45 milligrams/kg/dose PO twice daily) for 10 to 14 days.

images For children who present with severe symptoms, are in day care, or have recently been treated with antibiotics, prescribe cephalosporins such as cefprozil (7.5–15 milligrams/kg/dose PO twice daily), cefuro-xime (15 milligrams/kg/dose PO twice daily), and cefpodoxime (5 milligrams/kg PO twice daily).

images Intranasal steroids have shown modest benefits and are recommended if antibiotics do not result in improvement in the first 3 to 4 days of treatment.



images Herpangina, hand-foot-and-mouth disease (HFM), and herpes simplex gingivostomatitis are the primary infections that cause stomatitis and are all viral etiologies.

images The vast majority of pharyngitis is caused by viral infections (∼85%) including Epstein–Barr virus (EBV) pharngitis.

images Peak seasons for group A β-hemolytic Streptococcus (GABHS) pharyngitis are late winter or early spring, the peak age is 5 to 15 years, and it is rare before the age of two.


images GABHS and Neisseria gonorrhoeae are bacterial etiologies that require accurate diagnosis.

images The identification and treatment of GABHS pharyngitis is important in order to prevent the suppurative complications and the sequelae of acute rheumatic fever.


images Herpangina causes a vesicular enanthem of the tonsils and soft palate. The vesicles are painful and can be associated with fever and dysphagia.

images HFM disease usually begins as macules which progress to vesicles of the palate, buccal mucosa, gingiva, and tongue. Similar lesions may present on the palms of hands, soles of feet, and buttocks.

images Herpes simplex gingivostomatitis often presents with abrupt onset of fever, irritability, and decreased oral intake with edematous and friable gingival. Vesicular lesions, often with ulcerations, are seen in the anterior oral cavity.

images Symptoms of GABHS pharyngitis include sore throat, fever, headache, abdominal pain, enlarged anterior cervical nodes, palatal petechiae, and hypertrophy of the tonsils. With GABHS pharyngitis, there is usually an absence of cough, coryza, laryngitis, stridor, conjunctivitis, and diarrhea.

images EBV often presents much like streptococcal pharyngitis. Common symptoms are fever, sore throat, and malaise. Cervical adenopathy may be prominent and hepatosplenomegaly may be present.


images The diagnoses of herpangina, HFM, and herpes simplex gingivostomatitis are based on clinical findings.

images To diagnose GABHS, current guidelines recommend the use of Centor criteria: (a) tonsillar exudates, (b) tender anterior cervical lymphadenopathy, (c) absence of cough, and (d) history of fever. With two or more criteria, testing should be performed with a rapid antigen detection test and/or culture. If the rapid antigen test is negative, a confirmatory throat culture is recommended.

images Diagnosis of EBV is often clinical. The monospot test can aid in the diagnosis. The monospot may be insensitive in children <2 years of age and is often negative in the first week of illness. If obtained, the white blood cell count may show a lymphocytosis with a preponderance of atypical lymphocytes.


images Treatment of herpangina, HFM, and herpes simplex gingivostomatitis is primarily supportive. Systemic analgesics such as the combination of ibuprofen and tylenol should be considered. Occasionally oral narcotics may be required. IV hydration may be necessary if the child cannot tolerate oral fluids.

images Antibiotics for the treatment of GABHS pharyngitis are reserved for patients with a positive rapid antigen test or culture. Antibiotic choices for GABHS include penicillin (PCN) V 250 milligrams PO twice daily for children, 500 milligrams PO twice daily for adolescent/adults, benzathine PCN G 1.2 million U IM (600,000 units IM for patients weighing less than 27 kilograms), or erythromycin ethylsuccinate 10 to 20 milligrams/kg/dose PO twice daily for 10 days. Antipyretics and analgesics should be routinely prescribed until symptoms resolve.

images EBV is usually self-limited and requires only supportive treatment of antipyretics, fluids, and bedrest. A dose of dexamethasone 0.5 milligrams/kg PO to a maximum of 10 milligrams daily may be prescribed for more severe disease.



images Acute, unilateral cervical lymphadenitis is commonly caused by Staph. aureus or Streptococcus pyogenes.

images Bilateral cervical lymphadenitis is often caused by viral entities such as EBV and adenovirus.

images Chronic cervical lymphadenitis is less common but may be caused by Bartonella henselae (also called occuloglandular fever) or Mycobacterium species.


images Infectious agents are transported by afferent lymph vessels to lymph nodes.

images The lymph nodes filter infectious and antigenic materials from the lymphatic fluid, lymphocytes, then proliferate, causing subsequent nodal enlargement.


images Acute cervical lymphadenitis presents with tender nodules often with overlying erythema.

images Bilateral cervical lymphadenitis presents with small, rubbery lymph nodes and usually self-resolves after 3 to 5 days of symptoms.

images Bartonella henselae results from a kitten scratch with ipsilateral cervical lymphadenitis and sometimes associated conjunctivitis and fever (“occuloglandular fever”).


images Most cases are diagnosed clinically. Differential may also include sialoadenitis (infection of the salivary glands), which is usually caused by Staph. aureus or Strep. pyogenes. Malignancy and deep neck infections are additional considerations—the former are typically firm, immobile, and nontender; the latter are often associated with systemic signs such as fever and torticollis.


images For the treatment of acute cervical lymphadenitis, either amoxicillin plus clavulanic acid 15 to 20 milligrams/kg/dose twice daily or clindamycin 10 to 13 milligrams/kg/dose three times daily.

images The presence of a fluctuant mass may require incision and drainage in addition to antimicrobial therapy.

images Most cases of acute bilateral cervical lymphadenitis resolve without antibiotics, as they often represent viral infection or reactive enlargement.

images Chronic cases of lymphadenitis are often treated surgically, with directed antimicrobial therapy.

For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 114, “Ear and Mastoid Disorders in Infants and Children,” by David M. Spiro and Donald H. Arnold, and Chapter 118, “Neck Masses in Children,” by Osama Y. Kentab and Nadeemuddin Qureshi.