Updated: 12/17/2021

Otitis Media

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  • Snapshot
    • A 9-month-old boy presents to your urgent care clinic for increased irritability. One week prior to presentation, the patient had an upper respiratory infection, which has since improved. Over the last day, the mother has noticed that the child has been tugging at his right ear, refuses to lie down on it, and has had a fever. There is right tympanic membrane erythema that is bulging and minimally mobile with pneumatic otoscopy.
  • Introduction
    • Definition
      • middle ear infection
  • Epidemiology
    • Incidence
      • peak of acute otitis media infection is between 6-18 months of age
    • Risk factors
      • immunocompromise
      • viral upper respiratory tract infection
      • family history
  • Etiology
    • Infectious
      • Streptococcus pneumoniae (most common of the 3)
      • nontypeable Haemophilus influenzae
      • Moraxella (Branhamella) catarrhalis
    • Viral
      • respiratory syncytial virus
      • rhinovirus
      • adenovirus
      • coronavirus
      • influenza
      • parainfluenza
  • Pathoanatomy
    • Pathogenesis
      • typically, a viral upper respiratory tract infection leads to inflammatory changes to the respiratory mucosa of this aerated system
      • edema leads to obstruction at the isthmus of the eustachian tube, which poorly ventilates the middle ear, creating negative pressure
        • this results in secretions accumulating in the middle ear, which creates a favorable environment for microbial growth
    • Anatomy
      • the middle ear is an aerated system, which includes the mastoid air cells, eustachian tube, and the nares
        • respiratory mucosa lines this system
  • Presentation
    • Symptoms
      • nonspecific findings
        • fever
        • irritability
        • headache
        • poor oral intake and nausea
      • otalgia (most common complaint)
        • best predictor of acute otitis media
    • Physical exam
      • bulging or fullness of the tympanic membrane (TM)
      • erythema of the TM
      • possible perforation with otorrhea
      • possibe absence of light reflex
  • Studies
    • Pneumatic otoscopy
      • tympanic membrane bulging (most specific finding)
      • poor tympanic membrane mobility
      • tympanic membrane color is typically white or pale yellow
  • Differential
    • Otitis media with effusion
      • differentiating factors
        • tympanic membrane is retracted or in the neutral position
        • tympanic membrane is amber or blue
        • airfluid level or bubbles appreciated behind the tympanic membrane
  • Treatment
    • Medical
      • observation for a 2-day period
        • can be tried given high incidence of viral etiology
      • amoxicillin
        • indications
          • patients must have low-risk for amoxicillin resistance
          • in children < 6 months of age
          • in children 6 months-2 years of age with unilateral or bilateral acute otitis media
          • in children > 2 years of age who are toxic appearing, persistent otalgia (> 48 hours), or a temperature of ≥ 102.2°F (39°C) (> 48 hours)
          • in children > 2 years of age who have bilateral acute otitis media or ottorhea
        • comments
          • in patients who are at risk for amoxicillin resistance, give amoxicillin-clavulanate
          • in patients with an allergy to amoxicillin, give a macrolide or lincosamide
          • high dose is needed to overcome altered penicillin binding protein made by S. pneumoniae
      • amoxicillin-clavulanate
        • can be used as a second-line, if treatment failure with amoxicillin
        • can be used first-line if local resistance pattern to amoxicillin
  • Complications
    • Tympanic perforation
    • Tympanosclerosis
    • Cholesteatoma
    • Mastoiditis
    • Meningitis
    • Epidural and brain abscess
    • Cavernous sinus thrombosis
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Questions (4)

(M2.ET.17.4829) A 3-year-old boy presents to the pediatrician crying with ear pain and his temperature has been 101°F (38.3°C) for several days. His mother states that other children at his daycare center have been having similar symptoms. She further describes that he was fed formula and was not breastfed. The mother admits that she smokes cigarettes daily. On exam, the boy is irritable and crying, and frequently tugs on his left ear. Both tympanic membranes appear erythematous, and the left appears opaque and bulging with decreased mobility on pneumatic otoscopy. Which of the following is the best next step in management?

QID: 109460
1

Amoxicillin

56%

(20/36)

2

Amoxicillin-clavulanic acid

33%

(12/36)

3

TMP-SMX

0%

(0/36)

4

Tympanocentesis

0%

(0/36)

5

Supportive therapy

8%

(3/36)

M 6 C

Select Answer to see Preferred Response

(M2.ET.17.4678) A 3-year-old previously healthy female is brought to your office by her mother. The mother reports the child has been crying and pulling at her right ear over the past 2 days, and reports the patient has been febrile the past 24 hours. The patient’s past medical history is unremarkable, although the mother reports the patient had a “common cold” a week ago which resolved without intervention. Her temperature is 101.6 deg F (38.7 deg C), blood pressure is 100/70 mmHg, pulse is 120/min, and respirations are 22/min. Otoscopic exam is seen in Figure A. What is the most likely diagnosis?

QID: 107268
FIGURES:
1

Otosclerosis

0%

(0/3)

2

Malignant otitis externa

0%

(0/3)

3

Acute otitis externa

33%

(1/3)

4

Acute otitis media

33%

(1/3)

5

Otitis media with effusion

33%

(1/3)

M 6 C

Select Answer to see Preferred Response

(M2.ET.14.58) A 6-year-old previously healthy boy is brought to the emergency department for right ear pain. His mother states he has been pulling at his ear for the past 2 days and has complained of discomfort. She states he felt warm but has not taken his temperature. His birth history is unremarkable and he has no significant medical history. His temperature is 100.4°F (38.0°C), blood pressure is 94/54 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for the finding in Figure A. Which of the following is the most likely etiology of this patient's symptoms?

QID: 103548
FIGURES:
1

Moraxella catarrhalis

15%

(14/93)

2

Neisseria meningitidis

4%

(4/93)

3

Pseudomonas aeruginosa

2%

(2/93)

4

Staphylococcus aureus

4%

(4/93)

5

Streptococcus agalactiae

73%

(68/93)

M 6 E

Select Answer to see Preferred Response

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