Treat for AOM?

A 14-month-old female presented to the emergency department (ED) for fever and diarrhea.  Her mother reported the child had several episodes of crying in the previous two days. She denied vomiting but had three episodes of profuse watery diarrhea prior to arrival. Earlier that day, the child felt warm and had a temperature of 100.8^o F. In the ED, she appeared nontoxic but demonstrated stranger anxiety anytime a provider approached her—crying vigorously until they exited the room. Her vital signs were notable for a temperature of 39.5^oC, RR 45, HR 180. She had no rhinorrhea and a clear oropharynx. Her lungs were clear to auscultation, and she had a soft abdomen with hyperactive bowel sounds. The remainder of her physical exam was unremarkable.  Her Wispr digital exam is attached below.

Which of the following is true regarding this child’s tympanic membrane (TM)?

A. It is mildly bulging
B. It demonstrates evidence of a current acute otitis media (AOM)
C. It demonstrates evidence of a recent acute otitis media
D. All of the above

This child’s tympanic membrane (TM) is mildly bulging as evidenced by the indistinct malleus and slight central dimple. This is distinguished from moderate to severe bulging that takes on the appearance of an angry donut. In children with mild bulging, diagnosis of acute otitis media (AOM) also requires distinct erythema or additional symptoms of pain/fussiness or fever >39^oC. The child’s TM demonstrates prominent vasculature, and she had a fever of 39.5. Therefore one may consider this sufficient evidence to diagnose current AOM. However, the patient had several confounding factors including a diarrheal illness and vigorous crying—both of which could explain fussiness, erythema, and fever.  There are several spots of mucopurulence along the periphery of her TM, evidence of a recent bout of AOM that may be in the resolution phase. Upon further questioning, the mother reported her daughter completed treatment with amoxicillin approximately 10 days prior for AOM.

Given the clinical information—fever, fussiness, diarrhea (presumably from acute gastroenteritis), mild bulging with an erythematous and dull TM, as well as a recently treated AOM with evidence of some resolution—the next question becomes to treat or not to treat.  Perhaps this is what is meant by “the art of medicine?”  This author chose to defer immediate treatment with antibiotics (why worsen the diarrhea?) and provide a just-in-case prescription. The mother agreed to this plan and to provide supportive management for the GI illness while watching for the progression of ear complaints or fever. 

WiscMed has published a guide to the treatment of AOM that can be found here.

Key learning points

-Acute otitis media presents in a spectrum of severity based on the level of tympanic membrane bulging

-Treatment recommendations depend on fever, pain, erythema, and level of bulging

-Resolving AOM may be distinguished from developing AOM by the presence of mucopurulent spots

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