7-Month-Old with an Allergic Reaction

A 7-month-old male presented to the emergency department with concerns for an allergic reaction. The child had gone to an urgent care earlier in the day due to fever and fussiness where he was diagnosed with acute otitis media (AOM) and prescribed an antibiotic for treatment. Shortly after giving the antibiotic, the child vomited and seemed to have difficulty clearing his throat. They reported he had several episodes of nonbilious vomiting as well as diarrhea preceding the urgent care evaluation. In the ED, the child was afebrile and in no acute distress. He had several hives on his torso, which the parents noted had been present before the antibiotic. His lungs were clear to auscultation. His Wispr digital otoscope exam is attached.

Should the child continue with the antibiotic as prescribed? 

Yes or No?

The child’s Wispr exam demonstrates normal tympanic membranes (TMs) without bulging or erythema. He does not require antibiotics for his likely viral gastroenteritis, causing the fever, vomiting, diarrhea, and hives. The child received a small dose of anti-emetic in the ED, tolerated a feed, and was discharged home with recommendations to stop the antibiotic.

This case reinforces the importance of adequately visualizing the TM—a task that is often difficult in young infants. Note in the videos that both canals of this seven-month-old are occluded by hair and cerumen.  The Wispr digital otoscope successfully bypassed the obstructions, greatly facilitating assessment of the TMs, neither of which are bulging. In this child’s case, the over-diagnosis of AOM resulted in a cascade of events that added up to real-world burdens on the patient, family, and healthcare system: an inappropriately prescribed antibiotic, missed opportunity to manage the child’s viral illness appropriately, need for a second medical visit due to concern for side effect, time and effort by the medical center and staff to care for the child during this second visit, and parents missing work to bring the child to ED.

Overdiagnosis of AOM is unfortunately all too common, estimated to occur in up to a third of cases. A recent investigation estimated that each diagnosis of AOM has a direct cost of $633. When accounting for all costs, the economic burden of AOM in the U.S. is a staggering 5 billion dollars annually! If up to one-third of these cases are incorrect, the importance of competency in the diagnosis and management of otitis media is clear.

Reference:

Bhatia R, Chauhan A, Rana M, Kaur K, Pradhan P, Singh M. Economic Burden of Otitis Media Globally and an Overview of the Current Scenario to Alleviate the Disease Burden: A Systematic Review. Int Arch Otorhinolaryngol. 2024 Jul 5;28(3):e552-e558. doi: 10.1055/s-0043-1767802. PMID: 38974618; PMCID: PMC11226269.

Here are the left and right ear videos.