Otitis media

Question 1

Otitis Media
Jimmy Jay is a three-year-old boy. He is brought in by his mother who states “Jimmy was up all night with a painful left ear. He’s had the sniffles for the past week.”

Impression/DDx/Goals

Answer 1

Impression:
Likely a presentation of Acute otitis media given ear pain, coryza, demographic. Need to consider important risk factors in my assessment including indigenous heritage, age <6 months or bilateral/chronic/recurrent.

Want to rule out important/possible DDx including;

• COVID-19 infection
• Otitis externa
• Complicated AOM (mastoiditis, labrynthitis), middle-ear effusion
• URTI

Goals:

• Identify most likely aetiology
• Rule out other serious differentials
• Implement appropriate treatment and safety-netting according to likely diagnosis and risk profile

Question 2

Otitis Media - History

Answer 2

History:

• Sx: SOCRATES, URTI symptoms, sick contacts, RED FLAGS (productive cough, balance/hearing changes)
• PMHx: previous infections, presence of risk factors (indigenous, prior AOM, under 6 months, smokers at home, etc)
• Paediatric history: immunisations, pregnancy, developmental milestones

Question 3

Otitis media - Exam

Answer 3

Exam:

• Vitals
• ENT exam - bulging, red, opaque TM, loss of light reflex, effusion, inflamed external auditory canal
• Cervical lymph nodes: painful, rubbery, what-have-you
• Cardiorespiratory (auscultate lungs, chest)

Question 4

Otitis media - Investigations

Answer 4

Investigations

• No investigations usually required
• If complicated: Diagnostic imaging such as CT and MRI is usually only required in children with suspected intracranial complications
• Swab + MCS of middle ear effusion if present

Question 5

Otitis media - Management

Answer 5

Management:
Most cases of AOM in children resolve spontaneously and antibiotics are not recommended, only reduce overall symptom duration by ~12 hours

Non-pharm: mainly supportive

• Fluids/hydration
• Adequate nutrition

Pharm:

• Regular simple analgesia
• ​​As an adjunct, short-term use of topical analgesia eg 2% lignocaine, 1-2 drops applied to an intact tympanic membrane, may be effective for severe acute ear pain
• If risk factors present (<6mnths, indig etc), then antibiotics as per eTG
• If mastoiditis, then patients require IV flucloxacillin plus ceftriaxone

Antibiotics:

• Amoxicillin 500mg TDS for 5 days
• Refer to eTG for escalation of antibiotic treatment

Review/referral

• Persistent effusion beyond 3 months should trigger a hearing assessment and ENT involvement/referral
• Potential need for insertion of grommets

Safety netting:

• To re-present to GP if: non-resolving
• To present to ED if: acute deterioration, systemic symptoms, progression