PANCE Blueprint EENT (6%)

3 y/o with unilateral ear pain

Patient will present as → a 3-year-old previously healthy male is brought to your office by his mother. The mother reports the child has been crying and pulling at his right ear over the past 2 days and reports the patient has been febrile the past 24 hours. The patient's past medical history is unremarkable, although the mother reports the patient had a "common cold" a week ago which resolved without intervention. His temperature is 101.6 F, blood pressure is 100/70 mmHg, pulse is 120/min, and respirations are 22/min. The otoscopic exam is seen here.

AOM is usually precipitated by a viral URI, but the middle ear infection itself is bacterial in the great majority of cases (tympanocentesis studies detect bacteria in ~90%, often with viral co-infection). The bacterial causes mirror bacterial sinusitis, and the ranking has shifted since pneumococcal conjugate vaccines:

• Nontypeable Haemophilus influenzae – now the most common (34–60%); one-third to one-half of US strains produce beta-lactamase; associated with bilateral AOM and concurrent conjunctivitis ("otitis-conjunctivitis syndrome")
• Streptococcus pneumoniae – 15–25%; still the pathogen most associated with high fever, severe otalgia, and complications (mastoiditis, bacteremia)
• Moraxella catarrhalis – 12–15%; virtually all strains produce beta-lactamase
• Group A Streptococcus – 2–10%; older children, more TM perforation and mastoiditis

Acute vs. chronic vs. recurrent

• Acute: inflammation for less than 3 weeks
• Chronic: inflammation for greater than 3 months
• Recurrent: ≥ 3 episodes in 6 months or ≥ 4 episodes in 12 months (with at least one in the past 6 months) and clearing between episodes

Chronic OME (> 3 months)

• Clear serous fluid in the middle ear without signs or symptoms of acute infection
• May cause conductive hearing loss or be asymptomatic; does not require antibiotics

Clinical diagnosis by otoscopy — requires middle ear effusion + acute inflammation. Exam may reveal bulging, loss of landmarks, redness, injection of the TM, and pus

• Key findings are bulging of the TM and limited or absent mobility of the TM with pneumatic otoscopy — the most specific findings for AOM
• Erythema alone (from crying or fever) is not diagnostic — do not treat if the TM cannot be visualized or criteria are not met; re-examine if symptoms persist or worsen at 72 hours
• Bulging and eventual rupture of the TM can occur as well, leading to otorrhea and abruptly decreased pain

Acute otitis media - Note bulging, loss of landmarks, redness, injection of TM, and pus. Photo by Michael Hawke MD via Wikimedia Commons, CC BY 4.0.

Pain control for everyone — oral ibuprofen or acetaminophen whether or not antibiotics are started Children:

Antibiotic therapy vs. observation in children (AAP guideline)

Severe symptoms = toxic appearance, otalgia > 48 hours, or temperature ≥ 39°C (102.2°F). Observation requires reliable follow-up; start antibiotics if no improvement at 48–72 hours. Note: UpToDate now favors initial observation for most children who are not high-risk (high-risk = < 6 months, immunocompromised, toxic-appearing, craniofacial abnormalities) — the table above remains the board-tested standard.

First-line treatment for AOM in children

• Amoxicillin 90 mg/kg per day divided into two doses (maximum of 4 g/day) is the first-line drug of choice — high dose overcomes penicillin-nonsusceptible pneumococcus
• Augmentin 90 mg/kg per day of amoxicillin and 6.4 mg/kg per day of clavulanate divided into two doses (maximum 4 g/day of amoxicillin) is first-line for children who have received a beta-lactam antibiotic in the past 30 days, have recurrent AOM unresponsive to amoxicillin, or present with concurrent purulent conjunctivitis (beta-lactamase-producing NTHi)

AOM with perforation — amoxicillin 90 mg/kg per day orally divided in two doses (maximum 4 g/day) for 10 days; topical drops are not appropriate for a spontaneous perforation Treatment failure (no improvement at 48–72 hours)

• Failed amoxicillin → Augmentin
• Failed Augmentin or an oral cephalosporin → ceftriaxone 50 mg/kg IM once daily for 3 days (maximum 1 g/day); oral cephalosporins are not used after failure of high-dose amoxicillin

Children with a mild, non-IgE-mediated allergy to penicillin antibiotics (e.g., delayed rash)

• Cefdinir 14 mg/kg per day orally in one or two doses (maximum 600 mg/day)
• Cefpodoxime 10 mg/kg per day orally in two doses (maximum 400 mg/day)
• Cefuroxime tablets 250 mg orally every 12 hours (children > 17 kg who can swallow tablets; the suspension is no longer available in the US)
• Ceftriaxone 50 mg/kg intramuscularly once per day (maximum 1 g/day) for one to three doses

Azithromycin, clarithromycin, or clindamycin for the treatment of AOM in children who have had an immediate (IgE-mediated) hypersensitivity reaction or serious delayed reaction to amoxicillin or other beta-lactam antimicrobial agents

• Azithromycin 10 mg/kg per day orally (maximum 500 mg/day) as a single dose on day 1 and 5 mg/kg per day (maximum 250 mg/day) for days 2 through 5
• Clarithromycin 15 mg/kg per day orally divided into two doses (maximum 1 g/day)
• Clindamycin 30 mg/kg per day orally divided into three doses (maximum 1.8 g/day)
• ⚠️ These agents do not cover H. influenzae, and 25–35% of pneumococci are macrolide/clindamycin resistant — reserve for true allergy

Recurrent AOM — ≥ 3 episodes in 6 months or ≥ 4 in 12 months with persistent effusion → refer to ENT for tympanostomy tubes

Adults:

Since AOM is unusual in adults, and complications may be significant, treat all adult patients with antibiotic therapy (no observation) First-line acute otitis media (AOM) treatment in adults In most adults, use Augmentin 875/125 mg orally twice daily x 5 - 7 days as first-line abx.

• In patients with more severe infection or at high risk for severe or resistant infection (age > 65, immunocompromised, antibiotics in the past month, ≥ 10% local penicillin-nonsusceptible S. pneumoniae) — use a high dose of the amoxicillin component: Augmentin 2000 mg/125 mg, extended-release, orally twice daily

If Augmentin is unavailable or cost-prohibitive (and no amoxicillin allergy), amoxicillin may be used as initial therapy:

• Amoxicillin 500 mg TID or 875 mg BID x 5-7 days
• In patients at high risk for severe infections or infections with resistant S. pneumoniae, amoxicillin 1000 mg orally three times daily

In PCN allergic patients without severe reactions and who do not have a known allergy to a cephalosporin:

• Cefdinir, 300 mg orally twice daily or 600 mg once daily
• Cefpodoxime, 200 mg orally twice daily
• Cefuroxime, 500 mg orally twice daily
• Doxycycline, 100 mg orally twice daily
• Ceftriaxone, 1 to 2 g intravenously (IV) or 1 g intramuscularly (IM) once daily for three days

For patients with a known severe allergy to beta-lactam antibiotics or who have a known allergy to cephalosporins, antibiotic choices include:

• Doxycycline, 100 mg orally BID x 5-7 days
• Levofloxacin 500–750 mg orally once daily or moxifloxacin 400 mg orally once daily (respiratory fluoroquinolones; FDA boxed warning)
• Azithromycin (500 mg orally on day 1, then 250 mg on days 2 through 5) or clarithromycin (500 mg orally BID x 5-7 days) only if doxycycline and fluoroquinolones are contraindicated — high pneumococcal macrolide resistance

Adult treatment failure at 48–72 hours → high-dose extended-release Augmentin (if not already used), ceftriaxone IV, or a respiratory fluoroquinolone; obtain middle ear fluid culture via ENT if second-line fails Chronic OME:

• Treat with myringotomy with ventilation tube insertion if fluid is persistent (> 3 months) and/or causing hearing loss