Otitis media and externa (pediatrics): Clinical sciences

Otitis, or inflammation of the ear, is commonly caused by bacterial infection. It is most often seen in children, but it can occur at any age! Pediatric patients typically present with either acute otitis media, which is an infection of the middle ear most commonly caused by Moraxella catarrhalis, Streptococcus pneumoniae, or Haemophilus influenzae; or acute otitis externa, which is an infection of the outer ear, and is usually caused by Pseudomonas aeruginosa or Staphylococcus aureus.

If your patient presents with a chief concern suggesting acute otitis media or acute otitis externa, you should first perform a focused history and physical exam. Let’s start with acute otitis media. The history is usually significant for symptoms of discomfort; for instance, a nonverbal infant or child may be fussy, have changes in appetite or trouble sleeping, and they may tug, rub, or hold the affected ear. On the other hand, a verbal child will commonly describe new-onset ear pain. In addition, patients may or may not report ear drainage, fever, or concurrent symptoms of an upper respiratory infection, such as rhinorrhea, nasal congestion, and cough.

The physical exam using an otoscope will reveal a red, bulging tympanic membrane, as well as impaired mobility with pneumatic otoscopy. Keep in mind that redness is a non-specific sign of inflammation, so a sole finding of redness without bulging does not necessarily indicate acute otitis media. You may even see purulent drainage within the ear canal, which suggests that the tympanic membrane has ruptured.

Here’s a clinical pearl! A trick to systematically approach the otoscopic exam is to divide the tympanic membrane into four quadrants, and each quadrant should be assessed for its position, color, translucency, and mobility.

At this point, you can diagnose acute otitis media! Your next step is to assess the severity of otitis media by checking the patient’s temperature, as well as the degree and duration of otalgia. If the temperature is less than 39 degrees Celsius, or if there’s mild otalgia, or if the otalgia has been present for less than 48 hours, diagnose non-severe acute otitis media.

Next, before deciding on management, don’t forget to assess your patient’s age. First, let’s focus on children who are 2 years and older, whom you could choose to treat in one of two ways. In these patients, many cases of acute otitis media will resolve without antibiotics, so depending on the caregiver’s comfort level, you could choose to treat the patient’s pain with oral analgesics, such as acetaminophen or ibuprofen, and simply observe their symptoms, with close follow-up. This is called watchful waiting and requires reliable communication between the caregiver and the provider. Alternatively, you could provide both oral analgesia and high-dose amoxicillin.

Now, here’s a high yield fact! The first-line antibiotic choice for most patients with acute otitis media is high-dose amoxicillin, which is 90 milligrams per kilogram, divided twice daily and taken orally. However, if your patient has taken amoxicillin in the past 30 days, or if they also have purulent conjunctivitis, make sure to select an antibiotic with beta lactamase activity, such as amoxicillin-clavulanate. On the other hand, for patients with an amoxicillin allergy, you can choose a third-generation cephalosporin, such as cefdinir. Finally, patients who fail to improve with amoxicillin, amoxicillin-clavulanate, or cefdinir may require intramuscular ceftriaxone to adequately treat the infection.

Okay, now let’s go back and consider treatment options for patients between 6 and 23 months of age who have non-severe acute otitis media. In this case, your first step is to assess whether the otitis media is unilateral or bilateral. If the otitis is unilateral, treat your patient in the same way that you’d treat non-severe acute otitis media in children 2 years and older. First, you could choose to simply provide watchful waiting, giving oral analgesia, such as acetaminophen or ibuprofen, with observation and close follow-up. Alternatively, you could provide both oral analgesia and high dose amoxicillin. Again, before deciding, consider the caregiver's preferences and ability to follow up.

Now, here’s a clinical pearl! If you choose to observe your patient without starting antibiotics, but you’re not sure whether they’ll be able to follow-up in 48 to 72 hours, consider giving your patient a safety-net antibiotic prescription or “SNAP”, which allows a caregiver to fill the prescription and start antibiotics in the event that symptoms persist or worsen after 48 to 72 hours. A “SNAP” prescription should only be filled within the first 5 days after otitis media is diagnosed.

On the other hand, if your 6- to 23- month old patient has non-severe bilateral acute otitis media, provide oral analgesia, and start high dose amoxicillin right away, since watchful waiting is not recommended for bilateral otitis in this age group.