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 her mother. The mother reports the child has been crying and pulling at her 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.

The majority of all AOM is viral if a bacterial etiology is expected; the cause is the same as those seen in bacterial URI:

• Streptococcus pneumoniae 25%
• Haemophilus influenzae 20%
• Moraxella catarrhalis 10%

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 clearing between episodes

Chronic OM (> 3 months)

• Clear serous fluid in the middle ear without signs or symptoms of ear infection.
  • May have hearing loss, may be asymptomatic, does not require antibiotics.

An otoscopic examination may reveal bulging, loss of landmarks, redness, injection of TM, and pus

• Key findings include bulging of the TM and limited mobility of the TM with pneumotoscopy
• Building 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.

Children:

Antibiotic therapy vs. observation in children

First-line treatment for AOM in children

• Amoxicillin 90 mg/kg per day divided into two doses (maximum of 3 g/day) is the first-line drug of choice
• Augmentin 90 mg/kg per day of amoxicillin and 6.4 mg/kg per day of clavulanate divided into two doses is the first-line therapy for children with AOM who present with recurrent AOM, concurrent conjunctivitis or have received a beta-lactam antibiotic in the past 30 days.

AOM with perforation —  amoxicillin 90 mg/kg per day orally divided in two doses (we suggest a maximum of 3 g/day)

Children with a mild allergy to penicillin antibiotics

• 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 suspension 30 mg/kg per day orally divided in two doses (maximum 1 g/day)
• Cefuroxime tablets 250 mg orally every 12 hours
• Ceftriaxone 50 mg/kg intramuscularly once per day (maximum 1 g/day) for one to three doses

Azithromycin or clarithromycin for the treatment of AOM in children who have had an immediate 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)

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 at high risk for severe infections or infections with resistant S. pneumonia - high dose of the amoxicillin component:
  • Augmentin 1000 mg/62.5 mg, extended-release, orally twice daily (for lower-weight patients and/or those with milder infections)
  • Augmentin 2000 mg/125 mg, extended-release, orally twice daily (for higher-weight patients and/or those with more severe infections)

For those unable to tolerate Augmentin, alternatives include amoxicillin 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. pneumonia, 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
• 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 every BID x 5-7 days
• Azithromycin, 500 mg orally on day 1, then 250 mg orally on days 2 through 5
• Clarithromycin, 500 mg orally every BID x 5-7 days

Chronic OM:

• Treat with myringotomy with ventilation tube insertion of fluid is persistent and or hearing loss.