Young Child with Mild Ear Pain: Part 2

Young Child with Mild Ear Pain: Part 1

While the patient's initial course showed steady clinical improvement without antibiotics, the clinical picture took a turn. On day 6 of illness, the patient developed a fever of 38.1°C and experienced worsening, severe otalgia despite ongoing ibuprofen therapy. His Wispr digital otoscope exam images are attached below.

What is the most appropriate assessment and management for this child?

A. The child has a recurrence of acute otitis media and should start on amoxicillin
B. The child has acute otitis media and should continue to be under watchful waiting
C. The child should be given 3 doses of ceftriaxone due to bacterial resistance to acute otitis media
D. The child should have a CT scan of the mastoid bone to rule out mastoiditis

The child has now developed the classic signs of AOM based on severe bulging (angry donut sign) and a purulent MEE. The American Academy of Pediatrics (AAP) recommends a watchful waiting approach for children ages 6 to 24 months with unilateral acute otitis media (AOM) and mild symptoms, as well as for children over 24 months with either unilateral or bilateral AOM and mild symptoms. The patient in the above vignette was an appropriate candidate for this strategy, given his age and the absence of severe symptoms. Initial otoscopy findings suggested early signs of clinical improvement.

A critical component of the watchful waiting approach is providing a safety net antibiotic prescription (SNAP), to be used if symptoms persist beyond 48–72 hours or if there is a recurrence. Studies have shown that approximately one-third of children managed with observation will ultimately require antibiotics due to worsening or persistent symptoms. McCormick et al. (1) demonstrated that patients managed with watchful waiting had a lower risk of antibiotic-resistant organisms than those who failed initial antibiotic therapy.

For this patient, once symptoms worsened and a fever developed, initiation of first-line antibiotic therapy with amoxicillin was appropriate. Below is the progression of the tympanic membrane from day 1 through day 4 of treatment and then post-treatment.

Following a 7-day course of amoxicillin, the patient’s symptoms completely resolved.

Day 1 after treatment is initiated

Day 2 With Treatment

Day 3 With Treatment

Day 4 With Treatment

Day 14 Post-treatment

Key Learning Points:

· In cases of AOM managed with watchful waiting, a SNAP should be provided for use if there is no improvement after 48–72 hours or if symptoms recur.

· Recurrence of AOM can occur in both treated and untreated cases; approximately one-third of children managed with observation will require antibiotics.

· Serial otoscopy with photographic documentation can assist in monitoring the progression or resolution of AOM, especially when care is provided across different clinicians.

References:

Allan S. Lieberthal, Aaron E. Carroll, Tasnee Chonmaitree, Theodore G. Ganiats, Alejandro Hoberman, Mary Anne Jackson, Mark D. Joffe, Donald T. Miller, Richard M. Rosenfeld, Xavier D. Sevilla, Richard H. Schwartz, Pauline A. Thomas, David E. Tunkel; The Diagnosis and Management of Acute Otitis Media. Pediatrics March 2013; 131 (3): e964–e999. 10.1542/peds.2012-3488

David P. McCormick, Tasnee Chonmaitree, Carmen Pittman, Kokab Saeed, Norman R. Friedman, Tatsuo Uchida, Constance D. Baldwin; Nonsevere Acute Otitis Media: A Clinical Trial Comparing Outcomes of Watchful Waiting Versus Immediate Antibiotic Treatment. Pediatrics June 2005; 115 (6): 1455–1465. 10.1542/peds.2004-1665

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