Case 14: 18mo - acute otitis media

Question 1

Describe the findings for:

Normal ear

Answer 1

• translucent TM, in neutral, retracted position
• normal mobility
• can be red if child has been recently screaming / crying

Gray, normal mobility, neutral position, translucent

Question 2

Describe the findings for:

Otitis media with effusion (OME)

Answer 2

• fluid in middle ear space WITHOUT acute inflammation

Amber/red, nonmobile, retracted position, opaque

usually takes months to develop

Question 3

Describe the findings for:

Acute Otitis media (AOM)

Answer 3

• fluid in middle ear space WITH acute inflammation = bulging / fullness of TM, fever, and/or otalgia

White/red, reduced mobility, bulging, opaque

TM

• bullous myringitis = the TM looks like it has an bullous fluid-filled pocket.
• radial vascular dilation (bicycle-spoke distribution)
• marked erythema, with cobblestone appearance of TM

usually takes weeks to develop

Question 4

Describe the findings for:

Otitis externa

Answer 4

• “swimmer’s ear” == edematous external auditory canal +/- purulent material in external ear canal
• pain with traction on ear lobe

==> can be d/t perforation of TM in AOM

Question 5

RFs for acute otitis media (AOM)

Answer 5

• daycare attendance
• tobacco exposure
• allergies
• bottle propping in mouth at bedtime
• pacifier use
• formula feeding (v. breast feeding)
• significant Fhx of AOM
• male gender
• lower SES
• respiratory allergies
• conditions affecting craniofacial structure = cleft palate, Down syndrome
• ethnicity (Native Americans)

Question 6

Bacterial organisms in AOM

Answer 6

• strep pneumo
• nt H. flu (esp. if vaccinated against H. flu b)
• Moraxella catarrhalis
• Strep pyogenes

Question 7

Viruses in AOM

Answer 7

1) sole pathogen
2) alter mucosal lining == increased bacterial colonization of nasopharynx = VIRUS + BACTERIA ==> less responsive to antibiotic therapy

• RSV
• influenza
• rhinovirus

Question 8

Prognosis of AOM

Answer 8

50-80% spontaneous resolution

Question 9

Prognosis of otitis media with effusion

Answer 9

For several weeks after treatment of Abx

@ 1mo = 30-50% persistence of OME
@2 mo = 15-25%
@ 3 mo = 8-15%

Question 10

Potential testing modalities by an audiologist

- appropriate age

Answer 10

• tympanogram ==> mobility of TM
• conventional audiometry ==> behavioral test via earphones, for auditory thresholds in response to speech and freq-specific stimuli
  ==> 4y+
• visual reinforcement audiometry (VRA) ==> behavioral test via speakers in sound-treated room, for response of child to speech and frequency-specific stimuli. Response to stimuli rewarded with 3D animated toy. Not ear specific = assessing hearing only in better ear
  ==> 6mo-2.5y
• otoacoustic emissions (OAE) ==> physiological test in newborn assessment, for cochlear fx in response to presentation of a stimulus

Question 11

Describe pneumatic otoscopy

Answer 11

==> Assessment of the tympanic membrane = mobility, appearance
- otoscope + insufllation bulb

Question 12

Describe the ear exam

Answer 12

COMPT

C – olor = gray, white, amber, blue, red, yellow
O – ther = bubbles, air-fluid interface, scarring, perforation
M – obility = absent, reduced, normal, hypermobile
P – osition = normal, retracted, bulging
T – ranslucency = opaque, translucent

Question 13

Diffdx for “erythematous TM”

Answer 13

Fever, crying

Among many other things

Question 14

Diffdx for hx of fever, cough in a young child

• cause
• sxs:

Answer 14

ACUTE OTITIS MEDIA

• cause /timing of ear pain: 3-5d after onset of URI sxs (common complication)
• ear sxs: otalgia = ear pain, tugging (esp. if kid >12mo)
• other sxs: fever, irritability, cough, anorexia +/- V/D

SINUSITIS

• cause: (1) viral URI, (2) superinfection of pathogenic bacteria with same organisms as with otitis media
• sxs = persistent URI sxs >10d with day & night cough

URI
- cause: common cold
- sxs: Throat irritation, sneezing, nasal stuffiness, rhinorrhea, cough, fever, and
irritability

ALLERGIC RHINITIS
- cause: (seasonal rhinitis) = environmental allergens – airborne pollen; (perennial rhinitis) = indoor allergens/irritants – dust mites, anial dander, mold, tobacco

PNEUMONIA

• cause: bacteria > viral
• BACTERIAL sxs: abrupt onset of high fever, productive cough, ill appearance, +/- chest pain, dyspnea, tachypnea
• VIRAL sxs: moderate fever, nonproductive cough, gradual onset of URI sxs
• • younger children present with less specific sxs

Question 15

Management of AOM

Answer 15

Indications for treatment

• all children ages 6mo-2yo with UL AOM
• children >2yo with UL/BL AOM

1) Amoxicillin == for Strep pneumo (susceptible / intermediately resistant). Inexpensive, tasty, few s/e, narrow spectrum
2) high dose amoxicillin/clavulanate = for (1) resistant Strep pneumo (which is assumed if they have URI + otitis media), (2) + concurrent purulent conjunctivitis (d/t likely nt H.flu), (3) recurrent AOM, or (4) recent beta-lactam (for concerns of resistance)

Question 16

When to do antibiotic tx v. observation and close follow up in acute otitismedia

Answer 16

ANTIBIOTIC TX

• AOM with severe sxs = (1) toxic appearing child; OR (2) persistent ear pain > 48h OR (3) fever >39C within past 48h
• AOM with mild sxs = mild ear pain + temp <39C in past 48h

OBSERVATION AND CLOSE FOLLOW UP – assuming good follow up, and that Abx can be started if condition worsens / does not improve in 48-72h.
- AOM with mild sxs

Question 17

When to consider tympanostomy tubes

Answer 17

• persistence of middle ear fluid
• conductive hearing loss
• associated language delays
• suspected structural abnormalities to the eardrum / middle ear space
• pt develop problems with otalgia

Question 18

should OTC antihistamines/decongestants be given to an 18mo child?

Answer 18

NO

not to be given to <2yo –> lack of demonstrated benefit, reported adverse events (fatal overdoses)

Question 19

complications of acute otitis media

Answer 19

• middle ear effusions that persist for weeks after treatment with antibiotics
  ==> amber, non- or poorly mobile, opaque and retracted tympanic membrane. does NOT insufflate.
• hearing loss, language delay, learning problem
  ==> assess language development; hearing assessment.

Question 20

treatment of persistent OME

Answer 20

persistent OME = 3 months

1) Hearing assessment
- if normal == follow at 3-6-month intervals until effusion resolves OR child develops hearing deficit, language delay, structural abnormality
2) counseling, controlling environmental factors
3) myringotomy + tympanostomy tube placement ==> for chronic OME and b/l hearing loss
4) +/- speech therapy PRN; audiology PRN

NO Antibiotics / steroids

Question 21

complications of otitis media with effusion (OME)

Answer 21

• permanent sensorineural hearing loss, language delay, learning problem
  ==> assess language development; hearing assessment
• tympanosclerosis
• adhesive otitis media
• cholesteatoma

Question 22

roles / uses for Denver II screening tool

Answer 22

• Intended for use in children 0-6 years of age
• Includes assessment of social, fine-motor, language and gross-motor development
• Reports the percentage of children passing a specific task by age
• A screening tool used to identify children as “suspect” for delay

Question 23

complications of tympanostomy tube placement

Answer 23

• tube otorrea
• tympanosclerosis
• nonfunctional tube due to blockage
• residual perforation after extrusion of tympanostomy tubes
• RARE- sensorineural hearing loss d/t injury of round windo

Question 24

Rosy is an 18-month-old previously healthy baby girl who presents to clinic with congestion for three days. Today, her vitals are: T 101.2°F, BP 100/60 mmHg, P 80 bpm, RR 28 bpm. On physical exam, Rosy has clear mucus coming from both nostrils. Both turbinates show erythema. Her oropharynx is erythematous. No crackles or wheezing are heard. Mom reports that acetaminophen aids in bringing down the fever temporarily; however, the fever returns in a few hours. Mom is concerned for possible pneumonia since she was recently was given antibiotics for bronchitis. Her immunizations are up to date. Which of the following is most likely responsible for Rosy’s symptoms?

 Single Choice Answer:
Please select one answer.  
A		Strep pnuemoniae	
B		Group A Strep	
C		Rhinovirus	
D		Hemophilus Influenzae type B	
E		Pertussis

Answer 24

C

sinusitis + pharyngitis

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. Her symptoms all correlate with the common cold.

Question 25

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. 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?

 Single Choice Answer:
Please select one answer.  
A		Observation	
B		Anthistamines and decongestants	
C		High-dose amoxicillin	
D		Amoxicillin/clavulanate (with high-dose amoxicillin component)	
E		Tympanocentesis	
 Submit

Answer 25

D.

High-dose amoxicillin is the most common first-line treatment for acute otitis media due to its general effectiveness against susceptible and partially resistant S. pneumo, in addition to being low cost and having a high safety profile. However, this antibiotic was recently administered, raising concerns for a resistant organism.

amox+clavulanate == for concurrent pharyngitis;

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 26

An 18-month-old female is brought to her pediatrician by her mother who notes that she has been has been fussy for the past three days and has been pulling on her ears. The child is up to date with her hepatitis B, rotavirus, DTaP, H. influenza type B, pneumococcus, and polio vaccines. Her temperature is 102.2 F. Otoscopic exam of her left ear shows a yellow, opaque, and bulging tympanic membrane. Which of the following organisms is the most likely cause of the child’s condition?

 Single Choice Answer:
Please select one answer.  
A		Streptococcus pyogenes	
B		Candida albicans	
C		Haemophilus influenzae	
D		Rhinovirus	
E		Moraxella catarrhalis

Answer 26

C. H. flu untypeable

yellow, opaque, bulging TM

H. influenzae is a frequent cause of AOM (15–52% of cases). Although the child has been vaccinated against H. influenzae type B, this does not cover the unencapsulated strains of H. influenzae that cause AOM.

Question 27

An 18-month-old presents with yellow and poorly mobile tympanic membranes. Four months prior he presented then with several days of nasal congestion, cough, decreased eating and ear tugging. His exam then revealed a red, nonmobile tympanic membrane and he was treated with amoxicillin. Based on the history and physical exam, what is the most likely diagnosis now?

 Single Choice Answer:
Please select one answer.  
A		Mastoiditis	
B		Acute otitis media	
C		Otitis media with effusion	
D		Otitis externa	
E		Viral encephalitis

Answer 27

C

AOM at that point

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 28

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?

 Single Choice Answer:
Please select one answer.  
A		Allergies	
B		Maxillary sinusitis	
C		Asthma	
D		Frontal sinusitis	
E		Middle ear infection

Answer 28

B

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.