Case 14: 18mo - acute otitis media Flashcards
Describe the findings for:
Normal ear
- translucent TM, in neutral, retracted position
- normal mobility
- can be red if child has been recently screaming / crying
Gray, normal mobility, neutral position, translucent
Describe the findings for:
Otitis media with effusion (OME)
- fluid in middle ear space WITHOUT acute inflammation
Amber/red, nonmobile, retracted position, opaque
usually takes months to develop
Describe the findings for:
Acute Otitis media (AOM)
- fluid in middle ear space WITH acute inflammation = bulging / fullness of TM, fever, and/or otalgia
White/red, reduced mobility, bulging, opaque
TM
- bullous myringitis = the TM looks like it has an bullous fluid-filled pocket.
- radial vascular dilation (bicycle-spoke distribution)
- marked erythema, with cobblestone appearance of TM
usually takes weeks to develop
Describe the findings for:
Otitis externa
- “swimmer’s ear” == edematous external auditory canal +/- purulent material in external ear canal
- pain with traction on ear lobe
==> can be d/t perforation of TM in AOM
RFs for acute otitis media (AOM)
- daycare attendance
- tobacco exposure
- allergies
- bottle propping in mouth at bedtime
- pacifier use
- formula feeding (v. breast feeding)
- significant Fhx of AOM
- male gender
- lower SES
- respiratory allergies
- conditions affecting craniofacial structure = cleft palate, Down syndrome
- ethnicity (Native Americans)
Bacterial organisms in AOM
- strep pneumo
- nt H. flu (esp. if vaccinated against H. flu b)
- Moraxella catarrhalis
- Strep pyogenes
Viruses in AOM
1) sole pathogen
2) alter mucosal lining == increased bacterial colonization of nasopharynx = VIRUS + BACTERIA ==> less responsive to antibiotic therapy
- RSV
- influenza
- rhinovirus
Prognosis of AOM
50-80% spontaneous resolution
Prognosis of otitis media with effusion
For several weeks after treatment of Abx
@ 1mo = 30-50% persistence of OME
@2 mo = 15-25%
@ 3 mo = 8-15%
Potential testing modalities by an audiologist
- appropriate age
- tympanogram ==> mobility of TM
- conventional audiometry ==> behavioral test via earphones, for auditory thresholds in response to speech and freq-specific stimuli
==> 4y+ - visual reinforcement audiometry (VRA) ==> behavioral test via speakers in sound-treated room, for response of child to speech and frequency-specific stimuli. Response to stimuli rewarded with 3D animated toy. Not ear specific = assessing hearing only in better ear
==> 6mo-2.5y - otoacoustic emissions (OAE) ==> physiological test in newborn assessment, for cochlear fx in response to presentation of a stimulus
Describe pneumatic otoscopy
==> Assessment of the tympanic membrane = mobility, appearance
- otoscope + insufllation bulb
Describe the ear exam
COMPT
C – olor = gray, white, amber, blue, red, yellow
O – ther = bubbles, air-fluid interface, scarring, perforation
M – obility = absent, reduced, normal, hypermobile
P – osition = normal, retracted, bulging
T – ranslucency = opaque, translucent
Diffdx for “erythematous TM”
Fever, crying
Among many other things
Diffdx for hx of fever, cough in a young child
- cause
- sxs:
ACUTE OTITIS MEDIA
- cause /timing of ear pain: 3-5d after onset of URI sxs (common complication)
- ear sxs: otalgia = ear pain, tugging (esp. if kid >12mo)
- other sxs: fever, irritability, cough, anorexia +/- V/D
SINUSITIS
- cause: (1) viral URI, (2) superinfection of pathogenic bacteria with same organisms as with otitis media
- sxs = persistent URI sxs >10d with day & night cough
URI
- cause: common cold
- sxs: Throat irritation, sneezing, nasal stuffiness, rhinorrhea, cough, fever, and
irritability
ALLERGIC RHINITIS
- cause: (seasonal rhinitis) = environmental allergens – airborne pollen; (perennial rhinitis) = indoor allergens/irritants – dust mites, anial dander, mold, tobacco
PNEUMONIA
- cause: bacteria > viral
- BACTERIAL sxs: abrupt onset of high fever, productive cough, ill appearance, +/- chest pain, dyspnea, tachypnea
- VIRAL sxs: moderate fever, nonproductive cough, gradual onset of URI sxs
- younger children present with less specific sxs
Management of AOM
Indications for treatment
- all children ages 6mo-2yo with UL AOM
- children >2yo with UL/BL AOM
1) Amoxicillin == for Strep pneumo (susceptible / intermediately resistant). Inexpensive, tasty, few s/e, narrow spectrum
2) high dose amoxicillin/clavulanate = for (1) resistant Strep pneumo (which is assumed if they have URI + otitis media), (2) + concurrent purulent conjunctivitis (d/t likely nt H.flu), (3) recurrent AOM, or (4) recent beta-lactam (for concerns of resistance)
When to do antibiotic tx v. observation and close follow up in acute otitismedia
ANTIBIOTIC TX
- AOM with severe sxs = (1) toxic appearing child; OR (2) persistent ear pain > 48h OR (3) fever >39C within past 48h
- AOM with mild sxs = mild ear pain + temp <39C in past 48h
OBSERVATION AND CLOSE FOLLOW UP – assuming good follow up, and that Abx can be started if condition worsens / does not improve in 48-72h.
- AOM with mild sxs
When to consider tympanostomy tubes
- persistence of middle ear fluid
- conductive hearing loss
- associated language delays
- suspected structural abnormalities to the eardrum / middle ear space
- pt develop problems with otalgia
should OTC antihistamines/decongestants be given to an 18mo child?
NO
not to be given to <2yo –> lack of demonstrated benefit, reported adverse events (fatal overdoses)
complications of acute otitis media
- middle ear effusions that persist for weeks after treatment with antibiotics
==> amber, non- or poorly mobile, opaque and retracted tympanic membrane. does NOT insufflate. - hearing loss, language delay, learning problem
==> assess language development; hearing assessment.
treatment of persistent OME
persistent OME = 3 months
1) Hearing assessment
- if normal == follow at 3-6-month intervals until effusion resolves OR child develops hearing deficit, language delay, structural abnormality
2) counseling, controlling environmental factors
3) myringotomy + tympanostomy tube placement ==> for chronic OME and b/l hearing loss
4) +/- speech therapy PRN; audiology PRN
NO Antibiotics / steroids
complications of otitis media with effusion (OME)
- permanent sensorineural hearing loss, language delay, learning problem
==> assess language development; hearing assessment - tympanosclerosis
- adhesive otitis media
- cholesteatoma
roles / uses for Denver II screening tool
- Intended for use in children 0-6 years of age
- Includes assessment of social, fine-motor, language and gross-motor development
- Reports the percentage of children passing a specific task by age
- A screening tool used to identify children as “suspect” for delay
complications of tympanostomy tube placement
- tube otorrea
- tympanosclerosis
- nonfunctional tube due to blockage
- residual perforation after extrusion of tympanostomy tubes
- RARE- sensorineural hearing loss d/t injury of round windo
Rosy is an 18-month-old previously healthy baby girl who presents to clinic with congestion for three days. Today, her vitals are: T 101.2°F, BP 100/60 mmHg, P 80 bpm, RR 28 bpm. On physical exam, Rosy has clear mucus coming from both nostrils. Both turbinates show erythema. Her oropharynx is erythematous. No crackles or wheezing are heard. Mom reports that acetaminophen aids in bringing down the fever temporarily; however, the fever returns in a few hours. Mom is concerned for possible pneumonia since she was recently was given antibiotics for bronchitis. Her immunizations are up to date. Which of the following is most likely responsible for Rosy’s symptoms?
Single Choice Answer: Please select one answer. A Strep pnuemoniae B Group A Strep C Rhinovirus D Hemophilus Influenzae type B E Pertussis
C
sinusitis + pharyngitis
common cold and is the most reasonable diagnosis. Rhinovirus is a very common cause of congestion and other cold-like symptoms. Rosy presents with slightly elevated temperature, slight tachypnea, and inflamed turbinates and oral mucosa. Her symptoms all correlate with the common cold.
