Case 14

Question 1

What are key findings in the history of acute otitis media?

Answer 1

Fever, tugging at ears, congestion/rhinorrhea, cough, waking at night, maybe language delay

Question 2

What are key findings on physical exam for acute otitis media?

Answer 2

• First visit: TMs are bilaterally bulging, opaque, yellow/red, and poorly mobile
• Four months later: Bilateral, amber, nonmotile, retracted, opaque tympanic membranes

Question 3

What is the differential diagnosis for acute otitis media?

Answer 3

Upper respiratory infection, sinusitis, acute otitis media, pneumonia, allergies.

Question 4

What are key findings from testing with acute otitis media?

Answer 4

Hearing screen: mild hearing loss.

Question 5

Acute otitis media (AOM):

Answer 5

Infection of fluid in middle ear space.

Question 6

What are the most common etiologies of acute otitis media?

Answer 6

Bacterial:
-Strep pneumoniae (25-50 percent)
-H. influenzae, nontypeable (15-52 percent)
-Moraxella catarrhalis (3-20 percent)
-Step pyogenes (less than 5 percent)
Viral (viruses alter mucosal lining - increasing bacterial colonization of nasopharynx - or may act as sole pathogen): 
-RSV 
-Influenza
-Rhinovirus

Question 7

What are risk factors of acute otitis media?

Answer 7

Child care attendance, tobacco exposure, respiratory allergies, bottle propping, pacifier use, formula-feeding, family history of AOM, Male, lower socioeconomic status, onset of otitis in first year of life, conditions affecting craniofacial structure (cleft palate, down syndrome), genetic predisposition (native american)

Question 8

What are signs and symptoms of acute otitis media?

Answer 8

Prior or current upper respiratory tract infection, fever, fussiness, sleeplessness, otalgia (rubbing or tubbing at ears), decreased hearing, vomiting, poor appetite.

Question 9

Otitis media with effusion (OME):

Answer 9

Fluid in the middle ear space without signs and symptoms of acute inflammation

Question 10

Otitis externa (“swimmer’s ear”):

Answer 10

• Edematous external auditory canal
• Pain with traction on the ear lobe
• Occasionally follows perforation of the TM in AOM

Question 11

Physical exam with suspected ear infection:

Answer 11

Start with least invasive or potentially irritating aspects of the examination first:

• Observations of the child’s behavior, degree of alertness, and interactions with her parents.
• Examine heart, lungs, and abdomen
• Briefly look at the eyes for conjunctiva erythema or discharge (in case child cries with subsequent evaluation)
• Examine ears and oral cavity last

Question 12

Pneumatic otoscopy:

Answer 12

Enables assessment of the TM including its mobility through an otoscope using an insufflation bulb.

Question 13

Examination of patient’s ears:

Answer 13

Parent participation should be attempted first. Ears may be viewed most easily if child is placed:
-On parent’s lap
-On parent’s chest
-On the exam table
The pinna should be pulled up and back to help see past anterior bend in the external auditory canal.
Place hand close to the head of the otoscope to guard against sudden motions.

Question 14

What to look for on ear exam:

Answer 14

COMPT is a useful mnemonic to remember how to describe ear exam findings:
C - color (red, amber, blue, white, gray or yellow)
O - other (bubbles, scarring or perforation)
M - mobility (absent, reduced, normal or hyper mobile)
P - position (normal, retracted or bulging)
T - translucency (opaque or translucent)
A normal TM is translucent with neutral or retracted position and normal mobility.

Question 15

What is the Denver developmental assessment, 2nd edition?

Answer 15

• Standardized developmental screening tool for children birth to 6 years of age.
• Social, fine-motor, language, and gross-motor developmental domains are assessed for potential delays
• Subsequent referral for more definitive developmental testing should follow if screening reveals a concern

Question 16

What is on the differential diagnosis list for acute otitis media?

Answer 16

Upper respiratory tract infection (URI), Otitis media with effusion (OME), sinusitis, pneumonia, allergic rhinitis.

Question 17

What is on the less likely differential diagnosis list for acute otitis media?

Answer 17

Gastroenteritis and urinary tract infection (UTI)

Question 18

Upper respiratory tract infection (URI):

Answer 18

Symptoms vary depending on viral agent but may include throat irritation, sneezing, nasal congestion, cough and irritability.

Question 19

Acute otitis media (AOM):

Answer 19

Typically develops 3-5 days after onset of URI. Symptoms include fever and otalgia (tugging on ears in a younger child).

Question 20

Otitis media with effusion (OME):

Answer 20

Fluid (effusion) in middle ear without signs or symptoms of infection. May occur alone, secondary to URI or consequence of AOM.

Question 21

Sinusitis:

Answer 21

Caused by superinfection of pathogenic bacteria following viral URI. Persistent URI symptoms (greater than 10 days) with day and night cough are typical in pediatric cases.

Question 22

Pneumonia:

Answer 22

Bacterial pneumonia (much less common than viral) signaled by abrupt onset high fever, productive cough, and chest pain. May see dyspnea and tachypnea. Viral pneumonias often present with moderate fever, nonproductive cough.

Question 23

Allergic rhinitis:

Answer 23

May be seasonal or perennial depending on type of environmental allergen. Not likely if fever also present.

Question 24

Gastroenteritis:

Answer 24

Unlikely in absence of significant vomiting or diarrhea.

Question 25

Urinary tract infection:

Answer 25

UTI is an important cause of fever in girls 18 months of age, esp. for those with no apparent source of fever by history or exam. In the absence of a definitive source of fever (eg, pneumonia or otitis media), or in the setting of persistent fever, UTI should be reconsidered.

Question 26

Tympanogram:

Answer 26

Objective method for evaluating TM mobility.

Question 27

Conventional audiometry:

Answer 27

Behavioral test measuring auditory thresholds in response to speech and frequency-specific stimuli presented through earphones. Used for patients 4 years old and older.

Question 28

Visual reinforcement audiometry (VRA):

Answer 28

Behavioral test measuring response of the child to speech and frequency-specific stimuli presented through speakers in sound-proof room.
-Audiologic evaluation for kids aged 6 to 30 months, because conventional audiometry is not appropriate at very young ages.

Question 29

Otoacoustic emissions (OAE):

Answer 29

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

Question 30

Cough and congestion in an infant or young child:

Answer 30

The US Food and Drug Administration published an advisory in January 2008 that over the counter cough and cold products not be used for infants and children under 2 years of age due to lack of demonstrated benefit and prevalence of reported adverse events, including fatal overdoses.

Question 31

How often does AOM resolve spontaneously?

Answer 31

50-80 percent of the time!

Question 32

What is nonsevere illness defined as?

Answer 32

Mild ear pain and temperature less than 39 deg C in previous 24 hours.

Question 33

When can observation option be offered?

Answer 33

Only when good follow-up can be assured and antibiotics can be started should the child’s condition worsen or not improve in 48 to 72 hours.

Question 34

What are the complications of acute otitis media?

Answer 34

Mastoiditis, Meningitis, or intracranial spread.

Question 35

What should you do if you are certain OR uncertain of teh diagnosis for AOM at under 6 months?

Answer 35

Treat with antibiotic

Question 36

What should you do if certain of diagnosis from 6 mo-2 years?

Answer 36

Treat with antibiotic

Question 37

What should you do if certain of diagnosis at greater than 2 years?

Answer 37

Antibiotics if severe illness. Observation if nonsevere illness.

Question 38

What should you do if uncertain diagnosis between 6 mo-2 years?

Answer 38

Antibiotics if severe illness. Observation if nonsevere illness.

Question 39

What should you do if uncertain diagnosis greater than 2 years?

Answer 39

Observation.

Question 40

What are the two best antibiotics for AOM?

Answer 40

Amoxicillin and Amoxicillin/clavulanata (high-dose)

Question 41

Amoxicillin:

Answer 41

• Preferred first-line therapy for AOM
• Use high-dose regimen, 80-90 mg/kg/day
• Inexpensive
• Tastes good
• Relatively good safety profile
• Fairly narrow in antibacterial activity spectrum

Question 42

Amoxicillin/clavulanate (high-dose):

Answer 42

• Recommended by AAP and AAFP for children with higher fevers (greater than 39 C) or moderate to severe otalgia.
• Greater efficacy in treating nontypeable Hemophilus influenza, which is increasing in prevalence.

Question 43

Otitis media with effusion (OME):

Answer 43

• Cognitive effects of long-term OME are controversial
• If mild hearing loss but no language concern, “watchful waiting” for another 3-6 months with follow-up hearing test is an option
• If persistent OME, especially with associated language delay, referral for tympanostomy tube placement would be optimal
• No strong evidence that early placement of tympanostomy tubes in otherwise healthy children with persistent OME improves developmental outcomes at 3,4, 6 or 9-11 years of age.