Review Question - QID 103555

This child observed to be pulling at her ear with fussiness, fever, and a bulging tympanic membrane likely has acute otitis media. Given this patient's presentation, treatment with amoxicillin is the most appropriate next step in management.

Acute otitis media is one of the most common bacterial infections in children and has the highest incidence between 6 and 24 months of age. Common causative organisms include Haemophilus influenzae and Streptococcus pneumoniae. Viral otitis media is also common. Common symptoms include fever, otalgia, cough, and rhinorrhea. Parents will often report that they have noticed the child pulling at the affected ear. Diagnosis is usually performed by visualizing the tympanic membrane and performing pneumatic otoscopy, which reveal a bulging, erythematous, and non-mobile tympanic membrane and middle ear effusion. Antibiotic therapy is typically utilized for patients that are under 6 months of age, or those over 6 months that have high fever (>39°C), both ears affected, or severe pain. Amoxicillin is the standard first line antibiotic for otitis media in these patients.

Paul et. Al review the diagnosis and management of acute otitis media. They note the classic presentation of fever and ear pain, with fussiness being common in younger children. They recommend management with amoxicillin for most children that warrant treatment.

Figure A shows an erythematous, edematous otitis media consistent with acute otitis media. Illustration A is a treatment algorithm for acute otitis media.

Incorrect Answers:
Answer 2: Amoxicillin-Clavulanic acid may be appropriate for patients with recurrent otitis media, or those that do not respond to amoxicillin within a few days. However, it is not the most appropriate initial step.

Answer 3: Azithromycin may be appropriate for patients that have an allergy to penicillin. However, this patient has no stated allergies, so amoxicillin is more appropriate.

Answer 4: Cefdinir may be used for some patients with otitis media that are not able to take amoxicillin. However, it is not the first-line antibiotic for most patients with otitis media.

Answer 5: Observation and follow up exam in 3 months would be appropriate for patients with serous otitis media. However, this patient’s otoscopic exam findings demonstrate acute otitis media. Therefore, treatment with amoxicillin is warranted.

Bullet Summary:
Children with acute otitis media that are older than 6 months of age with fever, bilateral involvement, or excessive pain warrant treatment with amoxicillin.