14: 18-month-old female with congestion

Question 1

Otits media with effusion

Answer 1

Bilateral otitis media with effusion (OME) is best described as fluid in the middle ear space without signs and symptoms of acute inflammation (bulging or fullness of the tympanic membrane, fever and/or otalgia).

Question 2

Normal ear

Answer 2

• A normal middle ear generally has a translucent tympanic membrane (TM) that is in a neutral or retracted position.
• It has normal mobility.

Question 3

Otitis externa

Answer 3

• “swimmer’s ear,” is manifested by an edematous external auditory canal, and pain with traction on the ear lobe.
• An external otitis can occasionally follow perforation of the TM in AOM.

Question 4

Acute otitis media

Answer 4

• -A diagnosis of acute otitis media is supported by moderate or severe bulging of the tympanic membrane; OR mild bulging in the context of recent onset of pain or intense erythema of the TM.
• -AOM should not be diagnosed in the the absence of middle ear effusion, as determined by pneumatic otoscopy or tympanometry.

Question 5

Risk factors for acute otitis media (AOM) include:

Answer 5

• Day care attendance
• Tobacco exposure
• Allergies
• Bottle propping at bedtime
• Pacifier use
• Drinking formula from a bottle rather than breastfeeding
• Significant family history of AOM
• Male gender
• Lower socioeconomic status
• Respiratory allergies
• <>

Question 6

Bacterial causes of AOM are found in the following percentages:

Answer 6

Streptococcus pneumoniae
25-50%
Haemophilus influenzae, nontypeable
15-52%
Moraxella catarrhalis
3-20%
Streptococcus pyogenes
< 5%

Question 7

Middle ear effusions may persist at these rates for several weeks or even months after treatment with antibiotics.

Answer 7

1 month :30-50%
2 months :15-25%
3 months :8-15%

Question 8

Potential Testing Performed by an Audiologist: Tympanogram (1/4)

Answer 8

An objective method for evaluation of the mobility of the tympanic membrane.

Question 9

Potential Testing Performed by an Audiologist: Conventional audiometry (2/4)

Answer 9

Behavioral test measuring auditory thresholds in response to speech and frequency- specific stimuli presented through earphones.

Question 10

Potential Testing Performed by an Audiologist: Visual reinforcement audiometry (VRQ) (3/4)

Answer 10

Behavioral test measuring response of the child to speech and frequency-specific stimuli presented through speakers in a sound-treated room.

Question 11

Potential Testing Performed by an Audiologist: Otoacoustic emissions (OAE) (4/4)

Answer 11

Physiologic test measuring cochlear function in response to presentation of a stimulus. Primarily used in newborn assessments.

Question 12

What you should look for in an ear exam:

Answer 12

C = Color (gray, white, red or yellow)
O = Other (bubbles, air-fluid interface, scarring, or perforation)
M = Mobility (absent, reduced, normal, or hypermobile)
P = Position (normal, retracted, or bulging)
T = Translucency (opaque or translucent)

Question 13

Antibiotic Therapy for AOM

Answer 13

Amoxicillin remains the preferred first-line therapy for AOM because at appropriate dosages it is effective against susceptible and intermediately resistant S. Pneumoniae due to alterations in their penicillin-binding proteins. Amoxicillin also:
–is inexpensive,
–tastes good,
–has a relatively good safety profile, and
–is narrow in its spectrum of antibacterial activity.
The majority of cases of AOM resolve spontaneously. Treatment with antibiotics has been shown to shorten duration of symptoms (otalgia).

Question 14

Use antibiotic therapy in these cases

Answer 14

AOM with severe symptoms, defined as:

• -Toxic-appearing child, or
• -Persistent ear pain for 48 hours, or
• -Fever > 39 C within the past 48 hours

Question 15

OME persisting 4 months or longer and accompanied by hearing loss, documented language or other developmental delay, risk of developmental delay, or structural abnormality of the tympanic membrane or middle ear.

Answer 15

Tympanostomy tube placement should be considered in children

Question 16

Congestion, Cough, Fever DDx: Acute otitis media (1/4)

Answer 16

• Typically develops 3-5 days after onset of upper respiratory symptoms.
• One of the more specific symptoms is otalgia (ear pain, tugging at ears).
• Other symptoms include fever, irritability, cough, anorexia, and, less commonly, vomiting and diarrhea.
• Otitis media is a common complication of URIs in this age group.

Question 17

Congestion, Cough, Fever DDx: PNA (2/4)

Answer 17

• The typical childhood presentation of bacterial pna (much less common than viral) is the abrupt onset of high fever, a productive cough, an ill appearance and sometimes chest pain.
• PE can reveal dyspnea and tachypnea.
• Viral pneumonias more often present with moderate fever, a nonproductive cough and gradual onset of upper respiratory tract symptoms (younger children often present with less specific symptoms).

Question 18

Congestion, Cough, Fever DDx: Sinusitis (3/4)

Answer 18

• -Most episodes of sinusitis are thought to begin with a viral URI, followed by superinfection of pathogenic bacteria (the same organisms as in OM).
• -A diagnosis of sinusitis should be considered when symptoms are persistent (>10 days), worsening, or severe (e.g. fever > 39 degrees).

Question 19

Congestion, Cough, Fever DDx: Upper respiratory tract infection (4/4)

Answer 19

• -Depending on the viral agent, the presentation of the common cold is variable.
• -Throat irritation, sneezing, nasal stuffiness, rhinorrhea, cough, fever, and irritability are common symptoms of a URI.

Question 20

common cold

Answer 20

Rhinovirus causes the common cold and is the most reasonable diagnosis. Rhinovirus is a very common cause of congestion and other cold-like symptoms. Rosy presents with slightly elevated temperature, slight tachypnea, and inflamed turbinates and oral mucosa.

Question 21

A 14-month-old female with no significant past medical history presents to clinic with fever to 39.2 C and irritability. According to mom, the patient was initially sick one week ago with a runny nose and cough, but these symptoms had resolved. She started pulling at her ear and becoming increasingly irritable last night, with her fever spiking around 2:00 a.m. this morning. Patient is up to date on immunizations, and has had several prior ear infections. She was most recently treated last month with amoxicillin. When you examine her ears, you observe a red, bulging tympanic membrane with limited mobility in her left ear. The exam of the right ear is normal. You are confident in your diagnosis of acute otitis media. What is your treatment plan?

Answer 21

the severe symptoms our patient is exhibiting with a high temperature greater than 39 C. Amoxicillin/clavulanate is the treatment of choice for patients with moderate to severe otalgia or high fever, and is used for additional beta-lactamase coverage for Haemophilus influenzae and Moraxella catarrhalis, and when failure with amoxicillin is suspected.

Question 22

Otitis media with effusion

Answer 22

The earlier diagnosis of acute otitis media together with current findings of bilateral yellow and poorly mobile tympanic membranes on physical exam make this the most likely diagnosis

Question 23

An 8-year-old girl comes to the clinic with a chief complaint of a “cold” for the past two weeks. On further questioning, she developed a fever of 38.7°C, purulent nasal secretions, malodorous breath, and a nocturnal cough three days ago. Examination of the nose reveals pus bilaterally in the middle meatus, and tenderness over the mid-face. Which of the following is the most likely diagnosis?

Answer 23

The maxillary and ethmoid sinuses are large enough to harbor infection in infancy. The sphenoid sinuses do not become large enough until the third to fifth year of life, and the frontal sinuses are rarely large enough until the sixth to tenth year of life. Sinusitis is characterized by the findings in the question stem, and is often preceded by a URI. Pus draining from the middle meatus is suggestive of either maxillary, frontal, or anterior ethmoid sinusitis.