Pediatric Primary Care Case Studies, 1st Ed.

Chapter 22. The Toddler with Recurrent Ear Infections

Kathleen M. Boyd

In modern medicine, the primary care provider often relies heavily on advanced imaging technology and supportive laboratory evidence to clinch a diagnosis. On occasion, we are privileged to elucidate a clinical diagnosis based on just a thorough history and physical examination and provide treatment options based on that decision.

Educational Objectives

1.  Identify the distinguishing signs and symptoms of acute otitis media (AOM) and otitis media with effusion (OME).

2.  Apply the guidelines for management of acute otitis media and otitis media with effusion.

3.  Recognize the risk factors associated with development of acute otitis media.

4.  Identify when patients need to be referred to an otolaryngologist for treatment of otitis media.

  Case Presentation and Discussion

Sam Burgess is a 16-month-old African American boy who presents to your office with a history of fever, rhinorrhea, and tugging at his ear. He is accompanied by his mother, who is 12 weeks pregnant, and his 3-year-old brother, who also seems to have cold symptoms.

You talk with Sam’s mother about his presenting symptoms and past history and complete a detailed physical exam.

What questions will you ask Sam’s mother related to his fever and ear pain? image

Your symptom analysis reveals the following information: Sam started with a slight cough and runny nose 4 days ago. The rhinorrhea started with a small amount of clear discharge but has increased over the past 48 hours. Sam had been active and playful despite his symptoms until last night when his fever spiked to 102.2°F (39°C). His mother reports he was up most of the night crying and wanting to be held. He had one ear infection at 8 months of age and his mother is concerned that he may have another one because he is intermittently tugging at his right ear, acting as if it hurts. Ibuprofen has helped some with the fever and pain. Today Sam has been drinking well and has had several wet diapers, but he is not interested in eating. He has had no vomiting but his stools have been loose for the last 2 days.

What other questions do you need to ask Sam’s mother? image

Before answering this question, here is some more information about acute otitis media that you need to consider.

Epidemiology

Acute otitis media (AOM) is the most common bacterial infection in children, accounting for nearly 30 million clinic visits per year and costing over $5 billion in the United States yearly. It is the most frequent reason for childhood antibiotic consumption and outpatient surgery in developed countries (Rovers, Schidler, Zielhuis, & Rosenfeld, 2004). Fifty percent of U.S. infants have had at least one episode of AOM before 6 months of age, and 90% experience at least one episode by age 2 years (Siegel & Bien, 2004). There is an increased incidence in those younger than 2 years, with the peak age of incidence between 6 and 20 months. Males account for just over 50% of all cases.

Otitis media is especially prevalent and more severe among Native American, Inuit, and indigenous Australian children (Kerschner, 2007). Studies in the United States comparing otitis media rates among white and African American children have given conflicting results, but overall findings suggest that race-based difference rates seem most likely attributable to socioeconomic status, access to care, accuracy of diagnosis, and intensity of surveillance rather than race itself (Paradise et al., 1997).

Risk Factors

Age

The highest incidence for AOM is between 6 months and 2 years. Younger children are at increased risk for otitis media due to the relative immaturity of their immune systems. The developing immune systems of young children have less experience with common viruses than do those of adults. Viral infections likely are the direct or indirect cause of most middle ear infections (Kerschner, 2007).

More importantly, in infants and toddlers, the eustachian tube, responsible for draining middle ear secretions to the nasopharynx, is shorter, straighter, and floppier than an adult eustachian tube (Rovers et al., 2004). This straight, more easily closed design does not ventilate the middle ear as effectively, making it more susceptible to swelling, inflammation, and bacterial colonization (Maxson & Yamauchi, 1996).

Socioeconomic Status

Poverty has long been recognized as a major contributing factor in the development and the severity of OM. Recent studies strongly suggest that low socioeconomic status is one of the most important identifiable risk factors for the development of acute otitis media (Paradise et al., 2007). Crowded conditions, limited hygiene, suboptimal nutrition, limited access to health care, and limited resources for compliance with provider recommendations have all been suggested as playing a role in the relationship between poverty and the development of acute otitis media (Kerschner, 2007).

Secondhand Smoke Exposure

Passive smoke exposure increases the incidence of AOM and otitis media with effusion (OME), and the duration of the middle ear effusion. The precise mechanism remains unknown, but there is sufficient evidence to support a causal relationship between parental smoking and otitis media (U.S. Department of Health and Human Services, 2006). Recent studies suggest that nicotine and other toxins in secondhand smoke may enhance the invasion of bacteria into the middle ear and depress local immune function. Environmental tobacco smoke may cause toxic injury to the epithelium of the nasopharynx resulting in prolonged inflammation and congestion of the upper airways. It may also impair the mucociliary function of the eustachian tube and lead to impaired clearance of the nasopharyngeal airways (Kum-Nji, Meloy, & Herrod, 2006).

Etiology

Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis remain the leading bacterial pathogens responsible for acute otitis media (American Academy of Pediatrics [AAP], 2004). Viral infections, most commonly respiratory syncytial virus (RSV), influenza, and parainfluenza, are also common pathogens involved in AOM. It is uncertain whether viral infections alone can cause AOM, or whether their role is limited to setting the stage for secondary bacterial infection (Kerschner, 2007). It is suspected that viral co-infection amplifies the inflammatory process and contributes to delayed bacterial clearance (Rovers et al., 2004).

S. pneumoniae accounts for 25–50% of AOM, H. influenzae accounts for approximately 40% of cases, and M. catarrhalis is responsible for one eighth of the recognized bacterial otitis media. There is some evidence to suggest that the microbiology of acute otitis media is changing due to the routine use of the heptavalent pneumococcal vaccine, with more cases now attributable to gram-negative and beta lactamase–producing organisms (Block et al., 2004).

Pathophysiology

Dysfunction of the eustachian tube and inflammation are the most important factors in the development of AOM. Commonly, viral upper respiratory infections precede or coincide with AOM. The viral infections induce inflammation and edema in the nasopharynx and eustachian tube, narrowing the eustachian tube lumen. Obstruction of the lumen causes negative pressure to build up, creating a relative vacuum within the middle ear space. This phenomenon reverses the flow of secretions, pulling fluid from the nasopharynx into the middle ear (Siegel & Bien, 2004). The resulting mucoid medium is ideal for bacterial colonization and overgrowth, stimulating an even greater inflammatory response.

Data for the Diagnosis

Often the diagnosis of acute otitis media is evident by the history and physical examination findings, but, as in all realms of medicine, it is important to generate a differential diagnosis to ensure proper management and counseling for the patients. Viral myringitis and otitis media with effusion (OME) may be mistaken for acute otitis media. In myringitis, characterized by otalgia and an erythematous ear drum, the tympanic membrane is inflamed; however, it is nonbulging and freely mobile on pneumatic otoscopy (Siegel & Bien, 2004). On the other hand, OME is characterized by a poorly mobile, nonbulging TM, indicating the presence of middle ear fluid. In OME, the tympanic membrane lacks the characteristic inflammation that is seen in AOM.

The differential diagnoses also include otitis externa, or swimmer’s ear, which is an inflammation of the external auditory canal or auricle. Presence of a foreign body in the ear canal or impacted cerumen can also present as otalgia, but will typically lack the preceding upper respiratory infection (URI) symptoms and fever that accompany AOM, and will be evident on physical examination. Other diagnoses to consider when patients present with otalgia include local trauma, varicella zoster, herpes simplex, cellulitis or furunculosis of the ear canal, mastoiditis, and perichondritis. Referred pain from dental infections, stomatitis, pharyngitis, tonsillitis, and retropharyngeal abscesses must also be considered but are typically ruled out by physical examination (Sinai & Biggs, 2003).

From the above review, some other information you should obtain includes the following:

•  Is there smoke exposure in the home? (Increased risk for development of AOM)

•  Is the child breastfed? (Protective effect of breastmilk and breastfeeding if continued for at least 4 months)

•  Does the child attend daycare? (Increased risk for development of AOM)

•  Is there a family history of otitis media? (Increased risk for development of AOM with positive family history)

•  Does the child have any speech delays or other developmental concerns? (Concern for conductive hearing loss due to AOM)

•  Has the child been on antibiotics within the last month? (Increased risk for resistant organisms)

•  Does the child have AOM and purulent conjunctivitis? (Nontypeable H. influenzae)

•  Is there history of otorrhea? (TM perforation or myringotomy tubes)

•  Is there increased pain with traction on pinna? (Otitis externa)

•  Is the external auditory canal erythematous and/or edematous? (Otitis externa)

•  Is there a vesicular exanthem involving the auricle or ear canal? (Varicella zoster, herpes simplex)

Physical Examination

Upon physical examination, Sam is ill appearing and quiet in his mother’s lap. He has thick nasal discharge in both nares. Examination of the left tympanic membrane (TM) reveals a pearly gray tympanic membrane in neutral position. The light reflex and bony structures are clearly visible. Pneumatic otoscopy reveals movement of the left TM. The right tympanic membrane is cloudy, erythematous, and bulging. There are no visible landmarks. On pneumatic otoscopy of the right ear, there is no movement of the tympanic membrane. His oropharynx is moist and without erythema, ulceration, or exudates. Sam’s neck is supple and without lymphadenopathy. His eye, heart, lung, and abdominal examinations are unremarkable.

Making the Diagnosis

The history and physical examination are consistent with the diagnosis of acute otitis media, right ear. Diagnostic criteria for AOM include 1) rapid onset of symptoms, 2) presence of middle ear effusion, and 3) signs and symptoms of middle ear inflammation (AAP, 2004). Fever, irritability, rhinitis, cough, decreased oral intake, trouble sleeping, and tugging at the ears are often associated with AOM but are nonspecific symptoms that can be seen in many childhood illnesses (Rothman, Owens, & Siemel, 2003). It is important to remember that acute otitis media cannot be differentiated from a common viral upper respiratory infection based on symptoms alone.

A bulging, cloudy, immobile tympanic membrane is the most helpful physical finding to clinch the diagnosis (Rothman et al., 2003). Color is not a defining feature of acute otitis media because the infected middle ear may appear red or yellow (Siegel & Bien, 2004). However, a tympanic membrane that is distinctly red, or “hemorrhagic, strongly red or moderately red,” suggests AOM (Rothman et al.).

Detection of middle ear effusion by pneumatic otoscopy is a key element in the diagnosis of acute otitis media (AAP, 2004). Normally, the tympanic membrane is a convex, freely mobile, translucent barrier between the external ear canal and the inner ear. With insufflation, the healthy tympanic membrane moves easily in response to positive or negative pressure (Siegel & Bien, 2004). Normal mobility is evident when positive pressure is applied to the insufflator bulb and the eardrum moves rapidly inward; when the bulb is released, creating negative pressure, the TM moves out. The presence of a middle ear fluid, infectious or otherwise, significantly reduces the mobility of the TM. Evidence of middle ear effusion may also be demonstrated by the presence of purulent fluid in the external auditory canal, indicating a perforated tympanic membrane.

Management

How do you plan to treat Sam’s acute otitis media? image

Do you need to do anything to confirm the diagnosis, such as laboratory studies? image

Typically, no laboratory studies are needed to confirm the diagnosis of acute otitis media. However, AOM can often be difficult to diagnose by exam alone. When the presence of middle ear fluid is difficult to detect clinically, tympanometry or acoustic reflexometry can be helpful in establishing the diagnosis (AAP, 2004). A tympanometer records compliance of the TM and provides information on the function of the middle ear and the presence of a middle ear effusion. Acoustic reflectometry detects middle ear fluid by analyzing a sound gradient reflected off of the tympanic membrane (Ramakrishnan, Sparks, & Berryhill, 2007).

Although not routinely done, the definitive diagnostic test for AOM is culture of the middle ear fluid via tympanocentesis. The indications for tympanocentesis include a severely ill or toxic child, AOM in a newborn or immunocompromised patient, or clinical suspicion of an unusual organism (Siegel & Bien, 2004). The clinician must have expertise in completing this procedure.

Therapeutic plan: What will you do therapeutically? image

The goals of treatment for acute otitis media are twofold: pain management and reduction of recurrence. Nearly 80% of children with AOM will have spontaneous resolution within 2–14 days; therefore, it is not necessary that antibiotics be prescribed initially for all suspected cases of AOM (Rovers et al., 2004). Delaying antibiotics in select cases reduces antibiotic side effects, lowers treatment-related costs, and helps to minimize emergence of resistant bacterial strains (Ramakrishnan et al., 2007).

Children who will most likely benefit from antibiotic therapy are those younger than 2 years of age with severe AOM (defined as severe otalgia and fever > 39°C [102.2°F]), bilateral AOM, evidence of otorrhea on examination, and all children younger than 6 months of age (AAP, 2004). Children under 2 have a greater number of penicillin-resistant pneumococci isolated from the middle ear than older children; these infections are less likely to spontaneously resolve.

Antibiotics may be deferred in otherwise healthy children 6 months to 2 years of age in whom the disease is mild or the diagnosis is uncertain as long as there is a responsible, reliable caregiver and access to medical care if the symptoms worsen. Antibiotics may also be withheld in children older than 2 if the disease is mild or the practitioner is uncertain of the diagnosis, if in the presence of a reliable caregiver and ready access to medical follow-up (AAP, 2004).

Many practitioners have recently adopted a wait and see approach with regards to prescribing antibiotics because it allows for greater empowerment of the patient and family and enables shared decision making (Spiro & Arnold, 2008). It is a reasonable approach to give families a safety net antibiotic prescription (SNAP) with instructions not to fill the prescription unless symptoms worsen or fail to improve 48 hours after the initial visit (Spiro & Arnold). It is important to include an expiration date on the prescription within 5 days of the office visit.

The management of AOM should include a pain assessment and treatment of otalgia if present (AAP, 2004). Even with antibiotic therapy on board, significant otalgia may persist for up to 48 hours. A number of treatment options are available for pain management, including oral/rectal acetaminophen, ibuprofen, topical Auralgan (combination of antipyrine, benzocaine, and glycerin), and topical lidocaine. Antihistamines are not recommended and may prolong the middle ear effusion that often follows AOM. Decongestants may relieve nasal congestion but are not indicated in young children and do not improve healing or reduce complications of AOM (AAP, 2004).

When the decision is made to treat AOM with an antibiotic regimen, high dose amoxicillin is the preferred first line agent (AAP, 2004). Doubling the standard dose increases the drug concentration in the middle ear and provides activity against most intermediate strains of S. pneumoniae and many of the resistant strains. A 10-day antibiotic regimen is standard, but a 5- to 7-day regimen is adequate in older children with mild to moderate disease (AAP, 2004; Pickering, Baker, Long, & McMillan, 2006). In children who are vomiting and unable to tolerate an oral medication, an alternative for AOM management is a single dose of ceftriaxone, given intramuscularly or intravenously (Ramakrishnan et al., 2007).

Amoxicillin should not be first line therapy in patients who are at high risk for AOM caused by an amoxicillin-resistant organism. Those patients include children who have received antibiotics within the previous 30 days, patients with concurrent otitis and purulent conjunctivitis most likely due to nontypeable H. influenzae, and patients currently on amoxicillin prophylaxis (AAP, 2004; Pickering, Baker, Long, & McMillan, 2006). For children with penicillin allergy, please refer to Table 22-1 for antibiotic options. Table 22-2 outlines common agents used in the treatment of otitis media.

With appropriate antibiotic therapy and pain management, the signs and symptoms of systemic and local disease should begin to resolve within 24 to 72 hours. Lack of improvement in patients started on antibiotics suggests either bacterial resistance or the presence of another underlying disease process. High dose amoxicillin/clavulanate is the current recommended second line treatment option for persistent AOM. Cephalosporins such as cefdinir, cefpodoxime, cefuroxime, or a three-dose regimen of ceftriaxone are alternative regimens (AAP, 2004). Myringotomy or tympanocentesis to obtain cultures should be considered for cases that fail to respond to second line therapy (Pickering, Baker, Long, & McMillan, 2006).

Table 22–1 Antibiotic Options in the Penicillin-Allergic Patient

Type 1 Hypersensitivity (Presence of urticaria or anaphylaxis)

Non–Type 1 Hypersensitivity (No urticaria or anaphylaxis)

 

Azithromycin

Cefdinir

Erythromycin, sulfisoxazole

Cefuroxime

Clarithromycin

Ceftriaxone

Clindamycin


Cefpodoxime


When AOM is recurrent, despite appropriate antibiotic therapy, otolaryngology referral for possible surgical management with tympanostomy tubes is warranted. Recurrent AOM is defined as three episodes of AOM in 6 months or five to six episodes in 12 months (Kerschner, 2007).

In Sam’s case, you decide to prescribe high dose amoxicillin. His mother is instructed to give him the antibiotic by mouth twice daily for 10 days. Since his pain improved with ibuprofen, you encourage his mother to continue to use it as needed every 6 hours for ear pain.

Educational plan: What will you do to educate Sam’s mother about acute otitis media and its management? image

Points to make through discussion:

image  Explain the natural history of acute otitis media.

image  Explain the benefits of treating the ear pain with analgesics.

image  Explain the rationale of antibiotic use in the management of otitis media.

image  Reassure Sam’s mother that she should notice a decrease in his symptoms in 24–72 hours with the use of antibiotics and analgesics.

image  Educate Sam’s mother on the signs and symptoms of clinical deterioration.

image  Educate Sam’s mother on preventable risk factors.

image  Limit exposure to secondhand smoke.

image  Breastfeeding for at least 4 months (This may not help in Sam’s case but may help with AOM prevention in future siblings.)

image  Limit pacifier use after 6 months to only when the child is falling asleep.

image  Avoid bottle propping; enure infants are given bottles while upright.

image  Receive all appropriate vaccines, especially influenza and pneumococcal.

image  Limit exposure to others with upper respiratory infections.

When do you want to see this patient back again? image

Follow-up for AOM depends on the patient’s age and history of underlying medical problems, particularly speech delay, hearing loss, or learning problems (AAP, 2004). Persistent middle ear effusion after resolution of AOM is typical and should not be seen as treatment failure or need for continued antibiotics. Seventy percent of children will have middle ear fluid at 2 weeks, 40% at 4 weeks, and 10–25% at 3 months (AAP, 2004). Current guidelines recommend follow-up ear checks for all children younger than 2 years. This is typically done at 6 to 8 weeks. It is also recommended that children over 2 years who have a history of speech or developmental delay also be seen for follow-up after AOM (AAP).

Sam’s mother seems to understand the treatment regimen as explained and asks very appropriate questions. When she brings Sam back in 2 months for his previously scheduled 18-month well child visit, he seems to be doing well. On follow-up examination, the right ear is translucent and without erythema, but there is evidence of an air fluid level behind the TM. Pneumatic otoscopy reveals no movement of the TM when positive pressure is applied with the bulb. His left ear is completely normal, as is the remainder of his exam. Sam’s mother reveals that he is doing well developmentally and has a vocabulary of 10 words. Sam’s mother has no concerns with his hearing or speech.

Table 22–2 Agents Used in the Treatment of Acute Otitis Media

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Otitis Media with Effusion

Otitis media with effusion, or serous otitis, is present in nearly all children after successful treatment of acute otitis media (Pickering, Baker, Long, & McMillan, 2006). In the majority of patients, OME resolves without medical intervention, but it may take weeks to months to do so. Prolonged OME increases the risk for language delay due to the associated conductive hearing loss. Current guidelines for the management of OME recommend watchful waiting if the patient has no underlying language delays or hearing loss. Hearing tests are recommended if OME persists longer than 3 months, or sooner if language delay, learning difficulties, or hearing loss are suspected. There is no evidence to support the use of antihistamines, decongestants, corticosteroids, or antibiotics in the treatment regimen of OME (American Academy of Family Physicians [AAFP] et al., 2004). Otolaryngology referral is indicated for patients with high risk of speech or learning problems, particularly children with permanent hearing loss, children with craniofacial anomalies or syndromes that affect hearing and eustachian tube function, children with uncorrectable vision loss, and those children with a cleft palate (AAFP et al., 2004).

You decide to bring Sam back for an ear recheck in 6 weeks to evaluate for resolution of the OME. On follow-up, the middle ear fluid has resolved. He continues to do well developmentally and his mother has no new concerns.

Key Points of the Case

1. Otitis media is a clinical diagnosis that requires both evidence of middle ear effusion and signs and symptoms of middle ear inflammation on physical examination.

2. Assessment of the child’s pain and an appropriate plan for pain control should always be addressed in the management of acute otitis media.

3. Treatment of otitis media with antibiotics varies based on the child’s age, risk factors, and the constellation of symptoms, but high dose amoxicillin is typically the first line antibiotic agent.

4. It is not uncommon to have evidence of middle ear effusion after successful treatment of AOM.

5. The majority of cases of AOM and OME can be managed by the primary care practitioner, but referral to an otolaryngologist may be required in cases of treatment failure.

REFERENCES

American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, Subcommittee on Otitis Media with Effusion. (2004). Otitis media with effusion. Pediatrics, 113(5), 1412–1429.

American Academy of Pediatrics, American Academy of Family Physicians, Subcommittee on Management of Acute Otitis Media. (2004). Diagnosis and management of acute otitis media. Pediatrics, 113(5), 1451–1465.

Block, S. L., Hedrick, J., Harrison, C. L., Tyler, R., Smith, A., Findlay, R., et al. (2004). Community-wide vaccination with the heptavalent pneumococcal conjugate significantly alters the microbiology of acute otitis media. Pediatric Infectious Disease Journal, 23(9), 829–833.

Kerschner, J. E. (2007). Otitis media. In R. M. Kliegman, K. J. Marcdante, H. B. Jensen, & R. E. Behrman (Eds.), Nelson essentials of pediatrics (18th ed., pp. 2362–2646). Philadelphia: Elsevier Saunders.

Kum-Nji, P., Meloy, L., & Herrod, H. (2006). Environmental tobacco smoke exposure: prevalence and mechanisms of causation of infections in children. Pediatrics, 117(5), 1745–1754.

Maxson, S., & Yamauchi, T. (1996). Acute otitis media. Pediatrics in Review, 17, 191–195.

Paradise, J. L., Rockette, H. E., Colborn, K., Bernard, B. S., Smith, C. G., Kurs-Lasky, M., et al. (1997). Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life. Pediatrics, 99, 318–333.

Pickering, L. K., Baker, C. J., Long, S. S., & McMillan, J. A. (Eds.). (2006). Red book: 2006 report of the Committee on Infectious Diseases (27th ed.). Elk Grove Village, IL: American Academy of Pediatrics.

Ramakrishnan, K., Sparks, R. A., & Berryhill, W. E. (2007). Diagnosis and treatment of otitis media. American Family Physician, 76(11), 1650–1658.

Rothman, R., Owens, T., & Simel, D. (2003). Does this child have acute otitis media? Journal of the American Medical Association, 290(12), 1633–1640.

Rovers, M. M., Schidler, A. G. M., Zielhuis, G. A., & Rosenfeld, R. M. (2004). Otitis media. Lancet, 363, 465–473.

Siegel, R. M., & Bien, J. P. (2004). Acute otitis media in children: a continuing story. Pediatrics in Review, 25, 187–193.

Sinai, L. N., & Biggs, L. M. (2003). Earache. In: M. W. Schwartz, L. M. Bell, P. M. Bingham, E. K. Chung, D. F. Friedman, & A. E. Mulberg (Eds.), The 5-minute pediatric consult (3rd ed., pp. 32–33). Philadelphia: Lippincott, Williams & Wilkins.

Spiro, D. M., & Arnold, D. H. (2008). The concept and practice of a wait-and-see approach to acute otitis media. Current Opinion in Pediatrics, 20(1), 72–78.

U.S. Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.