CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
9-year-old with a Sore Throat
A 9-year-old presented to the emergency department (ED) for a sore throat and congestion. According to his mother, he had a mild cough for several days but no measured fever. He has not had a headache, ear pain, or muscle aches. In the ED, his vital signs were unremarkable, and he was generally well-appearing. He had clear rhinorrhea and mild oropharyngeal erythema. His Wispr digital otoscope exam is shown.
Which of the following is accurate regarding his clinical picture?
A. He has acute otitis media (AOM) and should immediately begin antibiotics
B. He has AOM and should be provided a safety net antibiotic prescription (SNAP)
C. He has otitis media with effusion (OME) and does not require antibiotics
D. A or B
Answer: D. A or B
The child’s right tympanic membrane (TM) demonstrates an “angry donut” appearance consistent with moderate to severe bulging. Recall that bulging, as a sign of both the presence of a middle ear effusion as well as inflammation, greatly increases the likelihood of AOM. But while the diagnosis of AOM is certain, the treatment decision is dependent on several factors, including the severity of symptoms, age, and unilateral versus bilateral involvement. The child in this case does not appear to have severe symptoms (lack of fever or ear pain), is older than 24 months, and has unilateral involvement. According to the AAP guidelines, Key Action Statement 3D for non-severe AOM in older children:
The clinician should either prescribe antibiotic therapy or offer observation with close follow-up based on joint decision-making with the parent(s)/caregiver for AOM (bilateral or unilateral) in children 24 months or older without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]). When observation is used, a mechanism must be in place to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of the onset of symptoms.
AOM differs from otitis media with effusion (OME) by the presence of bulging in AOM that is not present in OME.
The family agreed to the SNAP option—and ultimately did not fill the prescription. WiscMed has created a visual diagnosis guide that may be found here.
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