Among all of the causes of ear, nose, and throat (ENT) complaints, acute otitis media (AOM), bacterial sinusitis, and streptococcal pharyngitis (SP) are the most common infections prompting pediatric presentation to the ED. Through a series of case scenarios, along with key questions to help guide the clinician’s work-up, this review covers the proper evaluation and management of pediatric ENT complaints.
Case Scenario 1
A 13-month-old girl presented to the ED with a 1-day history of fever and runny nose. According to her parents, the child had been continually pulling on her ears in apparent discomfort. During history-taking, the parents further informed the emergency physician (EP) that the patient started daycare 4 months earlier and had two elementary school-aged siblings. The patient’s medical history was significant for otitis media, but the parents stated she had not been on antibiotics for over 4 months.
On physical examination, the patient’s vital signs were: blood pressure (BP), 75/50 mm Hg; temperature (T), 101.3°F; slight tachycardia; and normal age-adjusted respiratory rate (RR). Oxygen saturation was 100% on room air. The lungs were clear to auscultation and heart sounds were normal and without murmur. The otolaryngologic examination revealed copious yellow discharge from both nostrils, non-erythematous posterior oropharynx, and erythema to the right tympanic membrane (TM). Questions to Guide the Work-Up: (1) What physical examination findings should be present for accurate diagnosis of otitis media? (2) Will this patient require antibiotics immediately, or is a “wait-and-see” approach indicated? (3) If treatment with antibiotic therapy is warranted, what are the appropriate therapeutic regimen and duration of therapy?
Otitis Media
Acute otitis media is one of the most common presentations in young children. Defined as the rapid onset of signs and symptoms of middle ear inflammation, in conjunction with middle ear effusion (MEE), AOM can develop secondary to a viral or bacterial infection. It is estimated that more than 80% of the pediatric population will experience at least one episode of AOM by age 3 years.1-3
Risk factors for AOM include upper respiratory infection (URI), daycare attendance, siblings, parental smoking, and formula-feeding versus breastfeeding. The patient’s history may include rapid-onset otalgia, fever, irritability, anorexia, and concurrent URI symptoms, as well as other nonspecific symptoms (eg, ear rubbing and/or pulling, crying, changes in behavior and sleep patterns).2-4 In general, otalgia and ear-rubbing in the nonverbal patient seem to have the best predictive value for AOM.3
Signs and Symptoms
A normal TM should be translucent and pearly gray, with visible landmarks of the manubrium of malleus and pars flaccida. A TM that is bulging, cloudy, and immobile is the most consistent finding in AOM, with bulging having a specificity of 97%. Redness of the tympanic membrane is not a useful predictor of AOM as this finding is noted in upward of 30% of pediatric patients on general examination but in <1% of AOM diagnoses in the absence of a bulging TM.
Diagnosis
Pneumatic otoscopy is the gold standard for diagnosing for MEE; however, this examination can be difficult in younger, often uncooperative, patients. A TM that does not perceptibly move with either positive or negative insufflation pressure greatly enhances the diagnostic accuracy for MEE over the use of visible eardrum characteristics alone.2-5
Acute otitis media is a clinical diagnosis and does not require imaging studies or laboratory evaluation unless more serious processes, such as skull fracture, mastoiditis, or intracranial abscess, are being considered.2,3
Treatment and Management
Analgesia. The first step in managing patients with AOM is to provide analgesia. In most cases, acetaminophen in patients over 2 months of age, or ibuprofen in patients over 6 months of age, are adequate choices for managing pain. When either of these analgesics is administered in the clinic/ED setting, patients should be monitored to assure adequate pain relief prior to discharge.
While topical agents such as combination antipyrine-benzocaine suspensions were commonly given in the past to alleviate the pain associated with AOM, there are limited data to support their effectiveness. As such, in July 2015, the US Food and Drug Administration ordered manufacturers to halt production on these unapproved prescription products.3,4,6 There are also no randomized controlled trials (RCTs) to support the use of decongestants or antihistamines for resolution of AOM or otalgia.3,7
Antibiotic Therapy. The most common bacteria associated with AOM are Streptococcus pneumonia, nontypeable Hemophilus influenza, and Moraxella catarrhalis. In 30% of patients, the causative etiology is viral. When the decision is made to treat AOM, high-dose amoxicillin is still considered the first-line treatment, despite ever evolving susceptibilities of bacteria.
When a child is noted to have been treated with amoxicillin within a 30-day period or who has concurrent conjunctivitis, amoxicillin-clavulanate is considered the first-line treatment.2-4,7,8 The current American Academy of Pediatrics (AAP) guidelines recommend 10 days of antibiotic therapy for children younger than age 2 years, and 5 to 7 days for children older than age 2 years who have uncomplicated AOM. Intramuscular (IM) ceftriaxone is an acceptable first-line agent in a child who is unable to tolerate oral medications or who is suffering persistent emesis. Intramuscular ceftriaxone can be given as a single dose of 50 mg/kg, though the patient should be followed closely as studies show that a second dose may be necessary 5 to 7 days later to prevent infection recurrence. The IM dose of ceftriaxone 50 mg/kg can also be given if treatment with other antibiotics fails to resolve the AOM (failure is defined as no improvement in the patient’s condition 48 to 72 hours from treatment). In such cases, ceftriaxone is given in three consecutive doses.3,4,7
Wait-and-See Approach. Studies of patients whose AOM was confirmed via culture (19% were positive for S pneumoniae, 48% for H influenza, and 78% for M catarrhalis) showed bacterial clearance without antibiotic intervention.4 Based on these findings, the 2013 revised AAP evidence-based clinical practice guidelines indicate an initial watching-and-waiting period combined with pain management for patients older than 6 months of age who are diagnosed with unilateral AOM in the absence of severe symptoms (ie, fever is lower than 102.2˚F or patient has severe otalgia).4 A period of observation prior to treatment is also endorsed for children older than age 2 years who exhibit nonsevere symptoms—even if they have bilateral disease.4
Conversely, all patients younger than age 6 months and all children with severe symptoms should be treated with antibiotics at diagnosis.3,4 The wait-and-see approach, recommends an observation period of 24 to 48 hours for children in the lower risk group prior to antibiotic administration. Delayed antibiotic administration can be performed by a physician in an office/ED follow-up or as a safety-net antibiotic prescription (SNAP) sent home with the family on the initial ED encounter.2-4,8,9