Brief clinical information

1. z
Otitis Media
Camille Renee
Dr. MD
Pediatric Clerkship
Saint James School of Medicine
August 7 2018

2. An Acute-Onset Middle Ear
Infection caused by:
 Streptococcus pneumoniae
 Haemophilus influenzae
 Moraxella catarrhalis
 Viruses
 RSV
 Adenovirus
 Influenza
Viral upper respiratory infections cause edema in the eustachian
tube, leading to middle ear infection and subsequent inflammation.
https://i.ytimg.com/vi/68-hn6-XHmI/hqdefault.jpg
Kaplan USMLE Step 2 CK 2018

3. Kaplan USMLE Step 2 CK 2018
A shorter and more horizontal orientation of the eustachian tube allows for reflux
from pharynx ie. Infants and young children, larger adenoids also increases the risk

4. Physical Exam
 Ear Pain i.e. pulling of ear, irritability
 Fever
 Reduced Hearing
 GI symptoms
 Purulent Otorrhea (ruptured TM)
Symptoms
 Red Bulging Tympanic
Membrane (middle ear
effusion)
 Absent or Dull Light Reflex
 Immobility of Membrane on
Insufflation of the Ear with Air
Kaplan USMLE Step 2 CK 2018

5. https://simpleosce.com/img/mainpics/tympanic-membrane.jpg
https://img.medscapestatic.com/pi/meds/ckb/15/44915tn.jpg
Normal Abnormal

6. Dx Tests include Ear Insufflation via
Pneumatic Otoscopy or Tympanometry
An immobile tympanic
membrane on insufflation
is the most sensitive and
specific clinical finding for
otitis media
http://gojiactivesdiet.com/wp-content/uploads/2016/06/Abnormal-Tympanic-Membrane-bIFw.jpg
Kaplan USMLE Step 2 CK 2018

7. 1. Air-fluid level 2. Full, bulging tympanic membrane 3. Bulla formation; Otoscopic Signs at the
End of Treatment: Complete Resolution 4. Complete resolution of otoscopic signs of acute otitis
media; middle-ear fluid; Otoscopic Signs at the End of Treatment: Improvement 5. Partial
resolution of otoscopic signs of acute otitis media; middle-ear fluid with air--fluid level remains 6.
No improvement in otoscopic signs of acute otitis media; Otoscopic Signs at the End of Treatment:
Failure 7. No improvement in otoscopic signs of acute otitis media 8. Perforation of tympanic
membrane.
New England Journal of Medicine 2011

8. Complications
 Mastoiditis
 displacement of pinna inferiorly and
anteriorly
 Diagnose with CT scan of temporal
bone
 Treat with tympanotomy and IV
antibiotics
 Other complications include Delayed
Speech, Hearing Loss, Allergic
Rhinitis, Brain Abscess,
Cholesteatoma or Meningitis
Treatment
 Analgesics (acetaminophen, NSAIDs
except for Aspirin)
 1st line: High-dose Amoxicillin - 80 to 90
mg/kg/d for 7 to 10 days (Azithromycin
for patients with penicillin allergy)
 2nd line: Augmentin, IM ceftriaxone,
cefuroxime axetil, cefdinir
 Chronic otitis media can be treated with
tympanoplasty to reconstruct the middle
ear or tympanomastoid surgery
Step Up to Medicine 2016
Kaplan Medical USMLE Step 2 Lecture Notes 2018

9. Mastoiditis
Nursingtimes.net
Wikipedia

10. Otitis Media with Effusion (OME)
A condition in which fluid collects behind the
tympanic membrane but without signs and
symptoms of acute otitis media. Sometimes also
called serous otitis media.
Kaplan Medical USMLE Step 2 Lecture Notes 2018
http://www.texasearcenter.com
https://iytmed.com
Tympanostomy tubes
• Suggested for children with bilateral OME
and impaired hearing for >3 months;
prolonged unilateral or bilateral OME with
symptoms (school or behavioral problems,
vestibular, ear discomfort); or prolonged OME
in cases of risk for developmental difficulties
(Down syndrome, craniofacial disorders,
developmental disorders).

11. Question 1
A 5-year-old girl developed high fever, ear pain, and
vomiting a week ago. She was diagnosed with OM
and started on amoxicillin-clavulanate. On the third
day of this medication she continued with findings of
OM, fever, and pain. She received ceftriaxone
intramuscularly and switched to oral cefuroxime.
Now, 48 hours later, she has fever, pain, and no
improvement in her OM; otherwise she is doing well.
Which of the following is the most logical next step in
her management?
 A. Addition of intranasal topical steroids to the
oral cefuroxime
 B. Adenoidectomy
 C. High-dose oral amoxicillin
 D. Oral trimethoprim-sulfamethoxazole
 E. Tympanocentesis and culture of middle ear
fluid
 E. After failing several
antibiotic regimens,
tympanocentesis and
culture of the middle ear
fluid are indicated.
Case Files Pediatrics 5th Edition

12. Question 2
A 1-month-old boy has a fever to 102.7°F
(39.3°C), is irritable, has diarrhea, and has
not been eating well. On examination he has
an immobile red TM that has pus behind it.
Which of the following is the most appropriate
course of action?
 A. Admission to the hospital with complete
sepsis evaluation
 B. Intramuscular ceftriaxone and close
outpatient follow-up
 C. Oral amoxicillin-clavulanate
 D. Oral cefuroxime
 E. High-dose oral amoxicillin
 A. Very young children
with otitis media
(especially if irritable or
lethargic) are at higher
risk for bacteremia or
other serious infection.
Hospitalization and
parenteral antibiotics
often are needed.
Case Files Pediatrics 5th Edition

13. https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQSnTTvvw9tKH8_KI6KgRKCMXRKnAYArrTn1WNyXgX9HnOQoZCN