Acute Otitis Media

A 5-year-old presented to the emergency department (ED) with fever and congestion. His mother reported the child had a runny nose for nearly a week and had a fever of 101^o F at the onset of his illness. He was seen by his pediatrician three days before presentation and diagnosed with an upper respiratory infection. The child’s congestion had not improved so his mother brought him in for re-evaluation. He denied headache, sore throat, or ear pain, and had not been febrile in the previous 48 hours. In the ED, the child was afebrile with age-appropriate vital signs. He appeared well-hydrated. He had clear nasal drainage, but lungs were clear to auscultation with normal work of breathing. His Wispr digital otoscope exam is attached.  

Which of the following is the most accurate regarding this child’s presentation:

A. He has severe acute otitis media (AOM) and should be started on antibiotics immediately.
B. He has severe AOM and should be provided a “just in case” prescription for antibiotics to begin if the child worsens within 48 to 72 hours.
C. He has nonsevere acute otitis media (AOM) and should be started on antibiotics immediately.
D.  He has nonsevere AOM and should either be started on antibiotics immediately or be provided a “just in case” prescription to begin if the child worsens within 48 to 72 hours.

This case is a good illustration of the medical decision making required when assessing a child with potential AOM.  It can be easy to forget that diagnosis is primarily based on physical findings, while the management is primarily based on severity of symptoms and the child’s age.

The patient in this case has moderate bulging as evidenced by the complete loss of the malleus and the appearance of a reasonably deep central dimple (Note: we recognize bulging occurs on a continuum, and interpretation of the transition from mild to moderate is subjective. Our practice is to assess as mild bulging if the lateral process of the malleus is at least partially visible and the central dimple is shallow. According to the 2012 AAP practice guideline, this child should be diagnosed with AOM.

Key Action Statement 1A: Clinicians should diagnose acute otitis media (AOM) in children who present with moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to acute otitis externa. Evidence Quality: Grade B. Strength: Recommendation.

With the diagnosis of AOM being made, age of the child and assessment of severity guides management. Severe symptoms are considered if there has been more than 48 hours of ear pain, worsening ear pain, or fever of >39^oC. Nonsevere symptoms are considered less than 48 hours of mild ear pain and fever <39^oC. The patient in this scenario had neither ear pain nor high fever, therefore should be assessed as nonsevere.  According to the AAP guidelines, all severe AOM should be treated with antibiotics, while treatment of nonsevere AOM depends on age, whether uni or bilateral, and shared decision-making.

Younger than 6 months: prescribe antibiotics

6-23 months and bilateral: prescribe antibiotics

6-23 months and unilateral: Either prescribe antibiotics OR consider 48-72 hours observation and delayed prescription

Older than 24 months: Either prescribe antibiotics OR consider 48-72 hours observation and delayed prescription

From Key Action Statements 3C and 3D: 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 onset of symptoms

WiscMed has produced a guide to diagnosis and treatment of AOM that can be found here.

Key Learning Points

- Acute Otitis Media (AOM) is primarily diagnosed based on bulging of the tympanic membrane.

- Bulging can be mild, moderate, or severe.

- Management depends on age and symptoms.

Reference:

[Lieberthal%20AS,%20Carroll%20AE,%20Chonmaitree%20T,%20Ganiats%20TG,%20Hoberman%20A,%20Jackson%20MA,%20Joffe%20MD,%20Miller%20DT,%20Rosenfeld%20RM,%20Sevilla%20XD,%20Schwartz%20RH,%20Thomas%20PA,%20Tunkel%20DE.%20The%20diagnosis%20and%20management%20of%20acute%20otitis%20media.%20Pediatrics.%202013%20Mar;131(3):e964-99.%20doi:%2010.1542/peds.2012-3488.%20Epub%202013%20Feb%2025.%20Erratum%20in:%20Pediatrics.%202014%20Feb;133(2):346.%20Dosage%20error%20in%20article%20text.%20PMID:%2023439909.]Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA, Joffe MD, Miller DT, Rosenfeld RM, Sevilla XD, Schwartz RH, Thomas PA, Tunkel DE. The diagnosis and management of acute otitis media. Pediatrics. 2013 Mar;131(3):e964-99. doi: 10.1542/peds.2012-3488. Epub 2013 Feb 25. Erratum in: Pediatrics. 2014 Feb;133(2):346. Dosage error in article text. PMID: 23439909.

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