PANCE Blueprint EENT (7%)

Otitis media (ReelDx)

VIDEO-CASE-PRESENTATION-REEL-DX

Otitis media

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.

Otoscopic examination may reveal bulging, loss of landmarks, redness and injection of TM, pus. 

  • A key finding is 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 OM:

  • Amoxicillin x 10-14 days
  • Cefixime in children
  • Augmentin is 2nd line
  • If PCN allergic give Azithromycin, Erythromycin or Bactrim

Chronic OM:

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

bulging, loss of landmarks, redness and injection of TM, and pus

IM_NUR_OtitisMediaAssessment_V1.3_ Otitis media is an infection of the middle ear caused by a virus or bacteria and is characterized by the presence of fluid in the middle ear, along with symptoms of inflammation. This condition most commonly occurs in children due to the shorter, straighter, and narrower nature of the eustachian tube in childhood. Signs and symptoms of otitis media include red, bulging tympanic membrane, ear pain, and fever. Children with an upper respiratory infection or those regularly exposed to smoke are at an increased risk of developing an ear infection. Conductive hearing loss may occur in chronic cases of otitis media.  Antipyretics, analgesics, and antibiotics are typically used to treat otitis media, through irrigation of the ear, or procedures such as a myringotomy, or the placement of a tympanostomy tube may be necessary

Question 1
There is considerable debate about the use of tympanostomy tubes in the management of recurrent otitis media in children. Tympanostomy tube placement has been proven to
A
improve hearing
B
prevent mastoiditis
Hint:
Mastoiditis is prevented by early treatment of otitis media with antibiotics.
C
prevent recurrence of effusion
Hint:
Effusion can occur even with tympanostomy tubes in place.
D
prevent delayed language development
Hint:
Tympanostomy tubes have not been proven to prevent delayed language development.
Question 1 Explanation: 
Hearing is improved with tympanostomy tubes by eliminating middle ear effusion when the tubes are functioning properly.
Question 2
The most reliable sign of acute otitis media (AOM) is
A
bulging of the tympanic membrane
Hint:
Bulging and air bubbles behind the TM represent OM with effusion.
B
loss of tympanic membrane mobility
C
reddening of the tympanic membrane
Hint:
Reddening of the eardrum is not reliable as it may be due to crying or other vascular changes.
D
air bubbles behind the tympanic membrane
Hint:
See A for explanation.
Question 2 Explanation: 
Loss of tympanic membrane mobility during pneumoinsufflation is the most reliable sign for diagnosing acute otitis media.
Question 3
A patient with Type 1 diabetes mellitus was treated for otitis externa of the right ear for 2 weeks with topical ear drops. The patient presents today with persistent, foul aural discharge, granulations in the ear canal, and deep ear pain. Which of the following is the proper treatment at this time?
A
ciprofloxacin (Cipro) IV
B
cefuroxime (Zinacef) IV
Hint:
Cefuroxime, ampicillin-sulbactam, and azithromycin have no activity against Pseudomonas.
C
ampicillin-sulbactam (Unasyn) PO
Hint:
Cefuroxime, ampicillin-sulbactam, and azithromycin have no activity against Pseudomonas.
D
azithromycin (Zithromax) PO
Hint:
Cefuroxime, ampicillin-sulbactam, and azithromycin have no activity against Pseudomonas.
Question 3 Explanation: 
IV antibiotics directed against Pseudomonas, the most likely etiology, is needed for the treatment of malignant otitis media.
Question 4
Which of the following is the most likely organism in a 2 year-old child with acute otitis media?
A
Staphylococcus aureus
Hint:
See D for explanation.
B
Moraxella catarrhalis
Hint:
See D for explanation.
C
Pseudomonas aeruginosa
Hint:
See D for explanation.
D
Streptococcus pneumoniae
Question 4 Explanation: 
The most common pathogens in children with acute otitis media are Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes.
Question 5
A 3 year-old patient is brought in with a 10 day history of clear nasal drainage and cough which has now developed into otalgia and fever exceeding 101 degrees F for the last 5 days. Mom denies other chronic medical problems. The patient has had similar complaints three times in her life. Which of the following is the most likely causative organism?
A
Mycoplasma pneumoniae
Hint:
Mycoplasma pneumoniae is a common cause of bronchitis and pneumonia.
B
Pneumocystis jiroveci
Hint:
Pneumocystis jiroveci is associated with immunocompromised respiratory illness.
C
Pseudomonas aeruginosa
Hint:
Pseudomonas aeruginosa would most commonly cause otitis externa.
D
Streptococcus pneumoniae
Question 5 Explanation: 
Acute otitis media is a bacterial infection of the mucous lined air-containing spaces of the temporal bone most commonly caused by Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes.
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