We’re ear with a new episode with on acute otitis media joined by guest Dr. Eric Baum, a pediatric otolaryngologist in Connecticut. In this episode, we discuss important physical exam findings used to diagnose acute otitis media, as well as the role of pneumatic otoscopy in performing ear exams. Dr. Baum also tells us about treatment options for acute otitis media, how ear tubes work and when they are indicated, and complications to watch out for. Listen in to hear the latest on acute otitis media!
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Parents are key resources for assessing acute otitis media
The middle ear is a cavity that develops a purulent collection in acute otitis media
Ask about a change in eating patterns (see Expert Opinion, below)
Expert Opinion: Middle ear inflammation or acute change in pressure in the middle ear causes discomfort with swallowing or lying supine. Asking about anorexia can be a key part of history!
Spontaneous perforation is not common in AOM
Perforation can be followed by otorrhea and improved pain
Expert opinion: Perforated AOM presents an opportunity to use drops as therapy as there is an opening, and therefore, direct access, to the middle ear
Expert Opinion: Complications that occur as a result of AOM are generally idiosyncratic and not a result of prolonged undertreatment or missing of the diagnosis
Identifying complications of AOM on presentation can result in quicker treatment and improved outcomes
Symptoms that are concerning for complications of AOM include:
Typically viral infections precede the development of AOM (Conmaitree et al, 2008)
AOM is the result of nasopharyngeal carriage plus mucosal edema in a patient with an immature eustachian tube
A good history (Editor’s note: assessing for otalgia, signs of infection, otorrhea, ear tugging, irritability, changes in sleep, anorexia) provides useful pretest probability, and identifying the presence of purulent fluid on physical exam is helpful in making a diagnosis of AOM.
On otoscopy, increasing severity of AOM will display increased thickness and opacity of tympanic membrane, as well as increased bulging (Images on page e972 in Lieberthal et al, 2013)
Expert Opinion: On an otoscopic exam, try to discern what is behind the tympanic membrane and if there are engorged vessels on the surface of the tympanic membrane.
Pneumatic otoscopy can serve as a useful learning tool and provides helpful visual information
When using pneumatic otoscopy, ensure use of proper size and shape speculum
Pneumatic otoscopy can be uncomfortable in patients with AOM
Middle Ear Effusion (Image attributed to Michael Hawke, MD via Wikimedia licensed under the Creative Commons Attribution 4.0 International license)
Non-inflamed fluid in the middle ear is not an indication for treatment; however, it should be followed in a non-emergent fashion as it may be indicative of poor drainage of the middle ear
Fluid in the middle ear can be a cause of conductive hearing loss, which has implications for children, particularly in children with other risk factors for learning challenges including social barriers (Hogan et al, 2014; Su et al, 2020).
Persistent effusion in the long-term can be indicative of eustachian tube dysfunction
Eustachian tube dysfunction may be a risk factor for continued retraction, ossicular erosion, and cholesteatoma.
Cholesteatoma with perforated tympanic membrane (Image attributed to Michael Hawke, MD via Wikimedia licensed under the Creative Commons Attribution 4.0 International license)
Prevalence of Streptococcus pneumoniae and Nontypeable Haemophilus influenzae have changed over time due to the pneumococcal vaccine (Wald, 2019)
First-line antibiotic of choice is high-dose amoxicillin (Rettig, 2015)
There is some discrepancy in the suggested length of treatment for acute otitis media
Expert opinion: Cephalosporins such as cefdinir are also options for antibiotic treatment of AOM.
While viral upper respiratory infections can be the initial cause of bacterial AOM, there is no role for antiviral medications as therapy
Expert Opinion: After patients begin to improve with treatment, they should not get clinically worse. If they do have worsening symptoms on treatment, counsel patients to return to the clinic.
A myringotomy may be indicated in cases of in severe, worsening AOM following multiple trials of antibiotics
AOM can, in rare instances, be complicated by facial paralysis due to compression of the facial nerve or intracranial complications such as abscesses
Expert Opinion: Perforated AOM can occasionally appear to have improved symptoms due to relief of pressure following perforation
Expert Opinion: Perforated AOM presents an opportunity to use antibiotic drops as there is a direct opening
Expert Opinion: Fluoroquinolones are the topical antibiotic of choice in perforated AOM, allowing direct access to the middle ear in the case of perforation
Topical steroids may also be added in the treatment of perforated AOM to decrease the edema and increase drainage in the ear
Indicated in signs of persistent eustachian tube dysfunction, which may present with recurrent otitis media
Expert Opinion: Tympanostomy tubes work by improving air entry, allowing improved drainage through the eustachian tube
Patients with tympanostomy tubes who have AOM should be treated with topical antibiotic drops; they do not necessarily need oral antibiotics (Rosenfeld et al, 2013)
Listeners will develop a deeper understanding of the diagnosis, management, and potential complications of acute otitis media in children.
After listening to this episode listeners will…
Dr Baum reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.
Baum E, Rochat C, Chui C, Berk J. “Acute Otitis Media: Q-tips and Tricks with Dr. Eric Baum”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/March, 2020.
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