Updated: 8/8/2019

Otitis Media

Topic
Review Topic
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Questions
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Evidence
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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
    • anatomy
      • the middle ear is an aerated system, which includes the mastoid air cells, eustachian tube, and the nares
        • respiratory mucosa lines this system
    • 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
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
    • amoxicillin
      • indication
        • 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
Complications
  • Hearing loss
  • Tympanic perforation
  • Tympanosclerosis
  • Cholesteatoma 
  • Mastoiditis
  • Meningitis
  • Epidural and brain abscess
  • Cavernous sinus thrombosis
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.ET.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? Review Topic

QID: 109460
1

Amoxicillin

55%

(16/29)

2

Amoxicillin-clavulanic acid

34%

(10/29)

3

TMP-SMX

0%

(0/29)

4

Tympanocentesis

0%

(0/29)

5

Supportive therapy

7%

(2/29)

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(M2.ET.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?
Review Topic

QID: 107268
FIGURES:
1

Otosclerosis

0%

(0/0)

2

Malignant otitis externa

0%

(0/0)

3

Acute otitis externa

0%

(0/0)

4

Acute otitis media

0%

(0/0)

5

Otitis media with effusion

0%

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(M2.ET.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? Review Topic

QID: 103548
FIGURES:
1

Moraxella catarrhalis

13%

(11/84)

2

Neisseria meningitidis

5%

(4/84)

3

Pseudomonas aeruginosa

1%

(1/84)

4

Staphylococcus aureus

0%

(0/84)

5

Streptococcus agalactiae

80%

(67/84)

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