Bilateral Acute Otitis Media

A 4-year-old female is brought into the emergency department (ED) at 2 am for ear pain. The parents say that the child has had a cough, low-grade fever, and a runny nose for the past 3 days. Yesterday, she began to complain of pain in both ears and says the left ear hurts worse than the right ear. The parents gave the child Tylenol, which was only partially helpful in controlling the pain. The child has been unable to sleep. The child has had several episodes of ear infections in the past. The following image of her left ear is obtained with the WiscMed Wispr digital otoscope.

What is the next step in management?

The child has acute otitis media (AOM) in her left ear.

Based on the American Academy of Pediatrics (AAP) guidelines, this would be considered a severe case of AOM. The features that make this case severe include severe bulging, increased pain, and increased erythema (redness). Note that there is complete loss of visualization of the bones of the middle ear due to the bulging. The umbo dimple (caused by the attachment of the distal malleus to the eardrum) is pronounced.

It’s interesting to compare the child’s left ear to her right ear.

Note that the right ear also has bulging. However, the bulging is not as marked as in the left ear. The lateral process of the malleus is still discernable. In addition, the umbo dimple is not as pronounced. This would be considered moderate bulging. The moderate bulging with ear pain would still classify this ear as being severe AOM.

Given that the child has severe AOM in both ears and that she is 4 years old, the AAP guidelines recommend 7 days of antibiotics.

The AAP AOM practice guidelines can be found here. In addition, WiscMed has created a visual guide to common ear conditions that can be found here.