Case Files Pediatrics, (LANGE Case Files) 4th Ed.

CASE 13

A 4-year-old child complains of ear pain. He has a temperature of 102.1°F (38.9°C) and has had a cold for several days, but he has been eating well and his activity has been essentially normal.

Image What is the most likely diagnosis?

Image What is the best therapy?

ANSWERS TO CASE 13: Acute Otitis Media

Summary: A preschool child presents with ear pain and fever.

• Most likely diagnosis: Acute otitis media (AOM)

• Best therapy: Oral antibiotics

ANALYSIS

Objectives

1. Be familiar with the epidemiology of otitis media (OM) in children.

2. Understand the treatment of this condition.

3. Learn the consequences of severe infection.

Considerations

Otitis media is high on the differential diagnosis for this child with upper respiratory infection (URI) and ear pain. The diagnosis can be confirmed by pneumatic otoscopy and treatment started. A “telephone diagnosis” should be avoided. Figure 13-1 illustrates the anatomy of the middle ear.

image

Figure 13-1. Anatomy of the middle ear. (Redrawn, with permission, from Rudolph CD, Rudolph AM, Hostetter MK, Lister G, Siegel NJ, eds. Rudolph’s Pediatrics. 21st ed. New York, NY: McGraw-Hill; 2003:1240.)

APPROACH TO:

Acute Otitis Media

DEFINITIONS

ACUTE OTITIS MEDIA (AOM): A condition of otalgia (ear pain), fever, and other symptoms along with findings of a red, opaque, poorly moving, bulging tympanic membrane (TM).

MYRINGOTOMY AND PLACEMENT OF PRESSURE EQUALIZATION TUBES:A surgical procedure involving TM incision and placement of pressure equalization (PE) tubes (tiny plastic or metal tubes anchored into the TM) to ventilate the middle ear and help prevent reaccumulation of middle ear fluid.

OTITIS MEDIA WITH EFFUSION: A condition in which fluid collects behind the TM but without signs and symptoms of AOM. Sometimes also called serous OM.

PNEUMATIC OTOSCOPY:The process of obtaining a tight ear canal seal with a speculum and then applying slight positive and negative pressure with a rubber bulb to verify TM mobility.

TYMPANOCENTESIS: A minor surgical procedure in which a small incision is made into the TM to drain pus and fluid from the middle ear space. This procedure is rarely done in the primary care office, but rather is done by the specialist.

CLINICAL APPROACH

Otitis media is a common childhood diagnosis. Common bacterial pathogens include Streptococcus pneumoniae, nontypeable Haemophilus influenzae,and Moraxella catarrhalis. Other organisms, Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa, are seen in neonates and patients with immune deficiencies. Viruses can cause AOM, and in many cases the etiology is unknown. Acute OM is diagnosed in a child with fever (usually <104°F [40°C]), ear pain (often nocturnal, awakening child from sleep), and generalized malaise. Systemic symptoms may include anorexia, nausea, vomiting, diarrhea, and headache. Examination findings include a red, bulging TM that does not move well with pneumatic otoscopy. The TM may be opaque with pus behind it, the middle ear landmarks may be obscured, and, if the TM has ruptured, pus may be seen in the ear canal. Normal landmarks are shown in Figure 13-2.

image

Figure 13-2. The tympanic membrane. (Reproduced, with permission, from Rudolph CD, Rudolph AM, Hostetter MK, Lister G, Siegel NJ, eds. Rudolph’s Pediatrics. 21st ed. New York, NY: McGraw-Hill; 2003:1240.)

In some situations and in a child with few symptoms, a “watchful waiting” period of a few days may be indicated since many AOM cases self-resolve. Should antibiotics be deemed necessary and depending on a community’s bacterial resistance patterns, amoxicillin at doses up to 80 to 90 mg/kg/d for 7 to 10 days is often the initial treatment. If clinical failure is noted after 3 treatment days, a change to amoxicillin-clavulanate, cefuroxime axetil, azithromycin, cefixime, ceftriaxone, or tympanocentesis is considered. Adjuvant therapies (analgesics or antipyretics) are often indicated, but other measures (antihistamines, decongestants, and corticosteroids) are ineffective.

After an AOM episode, middle ear fluid can persist for up to several months. If hearing is normal, middle ear effusion often is treated with observation; some practitioners treat with antibiotics. When the fluid does not resolve or recurrent episodes of suppurative OM occur, especially if hearing loss is noted, myringotomy with PE tubes is often implemented.

Rare but serious OM complications include mastoiditis, temporal bone osteomyelitis, facial nerve paralysis, epidural and subdural abscess formation, meningitis, lateral sinus thrombosis, and otitic hydrocephalus (evidence of increased intracranial pressure with OM). An AOM patient whose clinical course is unusual or prolonged is evaluated for one of these conditions.

COMPREHENSION QUESTIONS

13.1 An 8-year-old boy has severe pain with ear movement. He has no fever, nausea, vomiting, or other symptoms. He has been in good health, having just returned from summer camp where he swam, rode horses, and water-skied. Ear examination reveals a somewhat red pinna that is extremely tender with movement, a very red and swollen ear canal, but an essentially normal TM. Which of the following is the most appropriate next course of therapy?

A. Administration of topical mixture of polymyxin and corticosteroids

B. High-dose oral amoxicillin

C. Intramuscular ceftriaxone

D. Intravenous vancomycin

E. Tympanocentesis and culture

13.2 Three days after beginning oral amoxicillin therapy for OM, a 4-year-old boy has continued fever, ear pain, and swelling with redness behind his ear. His ear lobe is pushed superiorly and laterally. He seems to be doing well otherwise. Which of the following is the most appropriate course of action?

A. Change to oral amoxicillin-clavulanate

B. Myringotomy and parenteral antibiotics

C. Nuclear scan of the head

D. Topical steroids

E. Tympanocentesis

13.3 A 5-year-old girl developed high fever, ear pain, and vomiting a week ago. She was diagnosed with OM and started on amoxicillin-clavulanate. On the third day of this medication she continued with findings of OM, fever, and pain. She received ceftriaxone intramuscularly and switched to oral cefuroxime. Now, 48 hours later, she has fever, pain, and no improvement in her OM; otherwise she is doing well. Which of the following is the most logical next step in her management?

A. Addition of intranasal topical steroids to the oral cefuroxime

B. Adenoidectomy

C. High-dose oral amoxicillin

D. Oral trimethoprim-sulfamethoxazole

E. Tympanocentesis and culture of middle ear fluid

13.4 A 1-month-old boy has a fever to 102.7°F (39.3°C), is irritable, has diarrhea, and has not been eating well. On examination he has an immobile red TM that has pus behind it. Which of the following is the most appropriate course of action?

A. Admission to the hospital with complete sepsis evaluation

B. Intramuscular ceftriaxone and close outpatient follow-up

C. Oral amoxicillin-clavulanate

D. Oral cefuroxime

E. High-dose oral amoxicillin

ANSWERS

13.1 A. The patient likely has an otitis externa that was caused by his swimming (also known as swimmer’s ear). Treatment is the application of a topical agent as described. Insertion of a wick may assist in excess fluid absorption in the macerated, swollen, and occluded ear canal. Causative organisms include Pseudomonas species (or other gram-negative organisms), S aureus, and occasionally fungus (Candidaor Aspergillus species).

13.2 B. The child has mastoiditis, a clinical diagnosis that can require computed tomography scan confirmation. Treatment includes myringotomy, fluid culture, and parenteral antibiotics. Surgical drainage of the mastoid air cells may be needed if improvement is not seen in 24 to 48 hours.

13.3 E. After failing several antibiotic regimens, tympanocentesis and culture of the middle ear fluid are indicated.

13.4 A. Very young children with OM (especially if irritable or lethargic) are at higher risk for bacteremia or other serious infection. Hospitalization and parenteral antibiotics often are needed.


CLINICAL PEARLS

Image The most common bacterial pathogens causing otitis media (OM) are S pneumoniae, nontypeable H influenzae, and M catarrhalis.

Image Examination findings of OM include a red, bulging tympanic membrane that does not move well with pneumatic otoscopy, an opaque tympanic membrane with pus behind it, obscured middle-ear landmarks, and, if the tympanic membrane has ruptured, pus in the ear canal.

Image Initial treatment of OM often includes amoxicillin (depending on local bacterial resistance patterns). If a clinical failure is seen on day 3, a change to amoxicillin-clavulanate, cefuroxime axetil, ceftriaxone, or a tympanocentesis is indicated.

Image Complications are rare but include mastoiditis, temporal bone osteomyelitis, facial nerve palsy, epidural and subdural abscess formation, meningitis, lateral sinus thrombosis, and otitic hydrocephalus.


REFERENCES

Haddad J. External otitis (otitis externa). In: Kleigman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: WB Saunders; 2011:2196-2199.

Kerschner JE. Otitis media. In: Kleigman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: WB Saunders; 2011:2199-2213.

Klein JO. Otitis media. In: Rudolph CD, Rudolph AM, Lister G, First LR, Gershon AA, eds. Rudolph’s Pediatrics. 22nd ed. New York, NY: McGraw-Hill; 2011:973-979.

Kline MW. Otitis externa. In: McMillan JA, Feigin RD, DeAngelis CD, Jones MD, eds. Oski’s Pediatrics: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1496-1497.

Kline MW. Mastoiditis. In: McMillan JA, Feigin RD, DeAngelis CD, Jones MD, eds. Oski’s Pediatrics: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1501-1502.

Rudolph C. Otitis externa. In: Rudolph CD, Rudolph AM, Lister G, First LR, Gershon AA, eds. Rudolph’s Pediatrics. 22nd ed. New York, NY: McGraw-Hill; 2011:979.

Schwarzwald H, Kline MW. Otitis media. In: McMillan JA, Feigin RD, DeAngelis CD, Jones MD, eds. Oski’s Pediatrics: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1497-1500.

Yoon PJ, Kelley PE, Friedman NR. Acute otitis media. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR. Current Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011:453-464.

Yoon PJ, Kelley PE, Friedman NR. Mastoiditis. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR. Current Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011:464-465.

Yoon PJ, Kelley PE, Friedman NR. Otitis externa. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR. Current Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011:452-453.