Otitis media and externa (pediatrics): Clinical sciences

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Introduction0:00–0:39

Otitis or inflammation of the ear is commonly caused by bacterial infection. It's 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 influenza 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.

Acute Otitis Media0:39–2:12

Let's start with acute otitis media. The history is usually significant for symptoms of discomfort.
For instance, a non verbal 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 nonspecific 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.

Acute Otitis Media - severity assessment2:12–2:47

If the temperature is less than 39 °C or if there's mild otalgia or if the otalgia has been present for less than 48 hours, diagnosed non severe acute otitis media.

Nonsevere Acute Otitis Media - 2 years and older2:47–4:23

Next, before deciding on management, don't forget to assess your patient's age first. Let's focus on Children who are two 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 mgs 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 activities such as amoxicillin clavulanate.
On the other hand, for patients with an amoxicillin allergy, you could 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.
Ok. Now, let's go back and consider treatment options for patients between six and 23 months of age who have non severe acute otitis media.

Nonsevere Acute Otitis Media - 6 to 23 months4:23–6:12

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 the same way that you treat non severe acute otitis media in Children.
Two 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 caregivers 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 five days after otitis media is diagnosed.
On the other hand, if you're 6 to 23 month old, a 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. All right.
Now that we've covered non severe acute otitis media. Let's go back and take a look at Children who have signs and symptoms consistent with severe acute otitis media.

Severe Acute Otitis Media6:12–6:52

These include a temperature of 39 °C or higher or moderate to severe otalgia or otalgia lasting 48 hours or longer. Patients with severe Otitis Media require antibiotic treatment regardless of age and laterality.
So begin oral analgesia in addition to high dose amoxicillin, as soon as you make the diagnosis for all patients with non severe and severe acute otitis media.

Assess Acute Otitis Media Treatment Response6:52–8:35

Regardless of the treatment, you select, make sure to assess the treatment response after 48 to 72 hours. If there is an inadequate response and the symptoms are still present or worsening, you should escalate treatment.
If you initially chose to manage your patient with watchful waiting, begin treatment with high dose amoxicillin. On the other hand, if you initially started your patient on high dose amoxicillin, then discontinue the amoxicillin and begin either amoxicillin, clavulanate or a third generation cephalosporin such as Cefdinir or cefTRIAXone.
Now, here's one last clinical pearl for otitis media, acute otitis media is a common infection in childhood and many Children have recurrent episodes defined as three or more infections in a six month period or four infections in a year.
With at least one in the preceding six months. Children with recurrent otitis media may require a surgical consultation for possible pressure equalization tube placement in order to drain middle ear fluid and lower the risk of future infections.
In addition, these tubes help prevent persistent middle ear effusions. Although middle ear effusions are not infections but rather collections of non purulent fluid that persist in the middle ear.
After acu otitis media resolves, they can cause transient hearing deficits leading to speech delays. So ultimately, by helping drain any middle ear effusion tube placement can also reduce the incidence of speech delays.

Acute Otitis Externa8:35–9:49

Now, let's go all the way back to the focused history and physical exam. But this time, let's consider acute otitis externa.
In this case, the history typically reveals new onset of otalgia along with a feeling of fullness in the ear. The patient may also describe ear drainage or decreased hearing and frequently they report recent swimming or instrumentation of the ear canal often with a cotton tipped swab.
Now, here's a high yield fact to keep in mind. Acute otitis externa often occurs in Children 5 to 14 years of age and it's frequently associated with water submersion, which explains its common name, swimmer's ear on physical exam.
Manipulation of the pinna of the affected ear typically elicits pain and visualization of the outer ear canal. With an otoscope may reveal edema, erythema, otorrhea or debris if these findings are present, diagnose acute otitis externa.
Ok. Now that you've diagnosed acu otitis externa, let's talk about treatment to start, make sure that your patient is following an ear hygiene regimen, which includes keeping the ears dry and avoiding swimming until the infection resolves.

Acute Otitis Externa Treatment9:49–11:07

Next, provide medical therapy, encourage pain management by providing oral analgesia with medications like acetaminophen or Ibuprofen as well as heating pads or ice packs applied topically to the ear.
Additionally, all patients with acute otitis externa require topical antibiotics such as a polymyxin, an amigo glycoside or fluoroquinolone.
And if more than half of the ear canal is occluded, consider placing a wick of ribbon gauze into the ear canal to help deliver medications to the epithelium of the ear canal.
More effectively. Finally, consider topical corticosteroids to alleviate swelling.
Now, here's a high yield fact, if you can't adequately visualize the tympanic membrane to ensure that it's intact, do not treat acute otitis externa with topical aminoglycosides or any other ototoxic medications since they could damage the inner ear if the tympanic membrane is perforated.
All right, as a quick recap, acute otitis media and acute otitis externa are conditions caused by a bacterial infection of the ear.

Review11:07–12:08

Acute otitis media can be classified as either non severe or severe depending on the patient's temperature as well as the degree and duration of pain.
Treatment of non severe otitis media depends on the patient's age and the laterality of the infection. And it includes oral analgesia with either watchful waiting or high dose amoxicillin.
On the other hand, severe otitis media should always be treated with antibiotics in both severe and non severe otitis media.
If there's no improvement in 48 to 72 hours, escalate treatment to high dose amoxicillin or switch to another antibiotic.
If amoxicillin was initially prescribed, finally, acute otitis externa is treated with ear hygiene, oral analgesia, topical antibiotics and you may consider topical corticosteroids.