Diagnosis
Diagnosis criteria for acute otitis media:
Moderate to severe bulging of the TM or new onset otorrhea not due to acute otitis externa
Highest predictive exam finding for AOM: Bulging TM, followed by cloudy TM and impaired TM mobility
The AAP recommends initial therapy with ____ alone for patients with AOM who have not received it in the past 30 days, do not have concurrent otitis and conjunctivitis, and are not allergic to penicillin.
Amoxicillin
____ should be used in those with recent amoxicillin use, conjunctivitis (increasing the likelihood H. influenzae), or history of AOM not responsive to amoxicillin.
Augmentin (amoxicillin-clavulanate)
- Also reasonable in other scenarios in which H. influenzae could be increasingly suspected (i.e. bilateral AOM)
Dolores Pinna, an 8-year-old, presents in August. Since her return from summer camp last week, she has complained of right ear pain and has had smelly yellow-green drainage. On exam, she winces when you manipulate her pinna. You find a right tympanic canal that is boggy, erythematous, and purulent. What you can see of the TM appears intact, in normal position, w/o significant erythema or opacification. What is your diagnosis?
Otitis externa (AKA Swimmer's ear)
Cause by breakdown of normal cerumen-skin barrier, most often via trauma or excessive exposure to water
Most common (bacterial) causes of AOM:
S. pneumoniae, H. influenzae, M. catarrhalis
The observation option involves "watchful waiting" for _____ [period of time] and subsequent initiation of treatment if no improvement or signs of worsening.
48-72 hours
- Often parents provided with time-limited Rx with specific instructions to use after observation to avoid the need for second visit
In the setting of _____ with otorrhea due to AOM, there is evidence that topical otic treatment is equally/more effective than systemic treatment.
Tympanostomy tubes
- Otic preparations can be either antibiotics or antibiotic-steroid combination
Otitis externa is most commonly caused by:
Pseudomonas aeruginosa
Also by S. aureus, some anaerobes
Most severe cases of AOM (i.e. bilateral AOM or otitis-conjunctivitis syndrome) are most often due to:
H. influenzae
Referral to ENT for tube placement may be considered in patients with:
Documented recurrent disease
- Debate on efficacy of tube placement - generally manifests as otorrhea, decreased pain, and topical treatments
The first step in prevention of recurrence should be parental education regarding:
Avoiding tobacco smoke and reducing pacifier use
This should be considered for mild cases that fail to respond to initial therapy without showing signs of worsening.
Fungi
Treat with topical acetic acid, alcohol, or clotrimazole
Most important risk factor for development of AOM:
Age - peak incidence between 6-18 months
-Children from low SES are at higher risk (poverty/household crowding)
-Exclusive breastfeeding for 6 months is protective
For patients with penicillin allergies, this is recommended for treatment of AOM.
Oral 2nd or 3rd generation cephalosporin or parenteral ceftriaxone
Most responds to single dose of Rocephin, but there is some data to suggest increased response rate with 3 daily doses
Patients with chronic Otitis Media with Effusion with retraction are at increased risk of developing:
Cholesteatoma
- Should be referred to ENT
First line of therapy for otitis externa:
Hygiene
Cleaning of ear debris, avoidance of water/trauma, followed by antimicrobials and agents to reduce inflammation and pain
Eve Fusion is 6 years old, and presents to your office with 4-5 days of URI symptoms though no significant fever. Her mother states, "I'm really concerned about her because she has a very high pain tolerance and has been tugging on her ears." She has been eating, attending school, and sleeping normally. On exam of her left ear, you find a translucent, retracted, poorly mobile TM, and a meniscus of clearish fluid behind the TM. Her right ear is similar in appearance. What is the diagnosis?
Otitis Media with Effusion
What is the standard dosing for the first-line treatment option for AOM?
Bonus: For what duration?
80-90 mg/kg amoxicillin divided BID for a duration of 10 days (<2 years old), 7 days (2-5 years old), 5-7 days (>5 years old)
Recurrent AOM is defined as:
3+ distinct episodes in 6 months, or 4+ episodes in 12 months
How to administer medications for OE:
Head turned with ear upwards --> ear filled with solution --> solution kept in contact with ear for 20 minutes (via positioning or cotton ball)
- Can use wick if partially obstructed, should be referred to ENT if fully obstructed