Just in time with a new USMLE® Step 2 CK Question of the Day! Today’s case involves a 3-year-old boy with ear pain in his right ear along with a cough and nasal congestion. The patient is on high-dose amoxicillin and acetaminophen, but returns 48 hours later for reassessment. What’s the best next step in managing his treatment?
A 3-year-old boy is brought to his primary pediatrician’s office for evaluation of ear pain. The parent reports that the patient has been holding the right ear in discomfort for the past 24 hours. They report an associated cough and nasal congestion. The patient was born full-term and has otherwise been healthy since birth. Temperature is 39.4°C (103°F), blood pressure is 107/55 mmHg, pulse is 102/min, respiratory rate is 32/min, and oxygen saturation is 99% on room air. Physical examination demonstrates an erythematous, bulging tympanic membrane with a purulent effusion and impaired mobility following insufflation. There is no otorrhea present. The patient is started on high-dose amoxicillin and acetaminophen for analgesia. Forty-eight hours later, the patient returns for reassessment with persistent ear discomfort. Repeat otoscopic examination demonstrates persistent erythema, bulging, and purulent effusion of the tympanic membrane. Which of the following is the best next step in management?
A. Complete the course of amoxicillin
B. Change amoxicillin to amoxicillin-clavulanate
C. Reassess in 48 hours
D. Administer topical corticosteroids
E. Administer topical neomycin
Scroll down for the correct answer!
The correct answer to today’s USMLE® Step 2 CK Question is…
B. Change amoxicillin to amoxicillin-clavulanate
Before we get to the Main Explanation, let’s see why the answer wasn’t A, C, D, or E. Skip to the bottom if you want to see the correct answer right away!
Incorrect Answer Explanations
Today’s incorrect answers are…
A. Complete the course of amoxicillin
Incorrect: This patient presents with persistent symptoms of otitis media following an initial treatment regimen with high-dose amoxicillin. This patient should receive broadened antibiotic therapy to adequately treat the infection.
C. Reassess in 48 hours
Incorrect: This patient presents with persistent symptoms of otitis media following an initial treatment regimen with high-dose amoxicillin. This patient should receive broadened antibiotic therapy to adequately treat the infection.
D. Administer topical corticosteroids
Incorrect: Topical corticosteroids are not indicated in the treatment of acute otitis media. Topical corticosteroids can be administered to patients with otitis externa.
E. Administer topical neomycin
Incorrect: Topical neomycin is not indicated for this patient with acute otitis media. Topical neomycin can be considered for patients with otitis externa only if it can be confirmed that the tympanic membrane is intact.
Main Explanation
This pediatric patient presents with acute ear pain and findings suggestive of acute otitis media. Diagnosis of acute otitis media is dependent on direct otoscopy of the tympanic membrane, which, in this case, revealed an erythematous, bulging tympanic membrane with impaired mobility. This patient has evidence of severe otitis media based on his fever >39 °C, mandating antibiotic therapy. Given the inadequate clinical response to initial treatment with high-dose amoxicillin, the best next step in management is to broaden antibiotic coverage by changing amoxicillin to amoxicillin-clavulanate.
Once a diagnosis of acute otitis media is established, severity can then be assessed by age and duration of illness. Patients with symptoms greater than 48 hours, moderate to severe otalgia, or a temperature >39 °C can be diagnosed with severe acute otitis media and require antibiotic therapy with high-dose amoxicillin. In contrast, patients with symptoms less than 48 hours, mild otalgia, or a temperature <39 °C can be diagnosed with non-severe acute otitis media and may or may not require antibiotic therapy based on the patient’s age and the presence of unilateral vs bilateral symptoms. Patients who are two years and older with non-severe AOM may be watched for 48-72 hours with analgesia alone or prescribed high-dose amoxicillin with follow-up at 48-72 hours to determine treatment response. In contrast, children aged 6-23 months with bilateral symptoms and non-severe AOM require antibiotics, while those with unilateral symptoms can be offered the option of treatment vs. close observation. Those with persistent or worsening symptoms at 48-72 hours should receive amoxicillin if it has not yet been tried, or they should start on broadened antibiotic therapy with either amoxicillin-clavulanate or a third-generation cephalosporin.
In contrast, treatment of otitis externa is more straightforward. Patients/parents should receive counseling regarding ear hygiene and should be provided with oral analgesia, topical antibiotics (e.g. polymyxin, neomycin, fluoroquinolone), with consideration of a topical corticosteroid if there is significant associated swelling.
Major Takeaway
In patients with otitis media, if clinical improvement has not occurred within 48-72 hours of antibiotic treatment with high-dose amoxicillin, the antibiotic coverage should be broadened to amoxicillin-clavulanate or cefdinir.
References
- For the diagnosis and management of otitis media with effusion. AAP. https://doi.org/10.1542/peds.113.5.1412
- (2013). Guidance for the diagnosis and management of acute otitis media. AAP. https://doi.org/10.1542/peds.2012-3488
- (2013). Guidance for the diagnosis and management of otitis externa. AAP. https://doi.org/10.1542/pir.34-3-143
- American Academy of Family Physicians; American Academy of Otolaryngology-Head and Neck Surgery; American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Otitis media with effusion. Pediatrics. 2004;113(5):1412-1429. doi:10.1542/peds.113.5.1412
- Long M. Otitis externa. Pediatr Rev. 2013;34(3):143-144. doi:10.1542/pir.34-3-143
- Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media [published correction appears in Pediatrics. 2014 Feb;133(2):346. Dosage error in article text]. Pediatrics. 2013;131(3):e964-e999. doi:10.1542/peds.2012-3488
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