Acute Otitis Media
Acute otitis media (AOM) is a suppurative infection of the middle ear caused by bacteria and viruses. It accounts for up to one-third of pediatric acute health care visits. The incidence is highest during the winter months, secondary to the greater frequency of viral upper respiratory infections (URIs). Children with normal immunity may have multiple episodes in a year. Risk factors for AOM include daycare attendance, second-hand smoke exposure, use of a pacifier, bottle feeding, and a family history of ear infections. Children with Down syndrome or craniofacial abnormalities are at increased risk of otitis media.
The most common bacterial etiology identified is Streptococcus pneumoniae (30–40%), which is now decreasing in frequency secondary to vaccination, followed by nontypable Haemophilus influenzae (20–30%), Moraxella catarrhalis (10–20%), and Streptococcus pyogenes. Gram-negative enteric organisms (Escherichia coli, Klebsiella, Proteus, Pseudomonas) and Staphylococcus aureus are responsible for about 15% of cases in the first few months of life, but are exceedingly rare afterward. Viruses, including parainfluenza, respiratory syncytial virus, influenza, adenovirus, and enterovirus are common pathogens (up to 50% of cases).
Clinical Presentation
Acute otitis media is usually preceded by a URI with cough and rhinorrhea. Additional symptoms begin 2–3 days later and may include fever, pain, dizziness, buzzing in the ear, or decreased hearing. In infants, there are nonspecific symptoms, such as irritability, increased crying, decreased feeding, sleep disturbance, vomiting, or diarrhea. In younger patients there may only be fever, a persistent URI, or behavioral changes (cranky, not feeding or sleeping well). Ear tugging is an unreliable sign of AOM. Occasionally, there is a history of severe ear pain that improved abruptly when a bloody or yellowish discharge began to drain from the external canal (tympanic membrane perforation). In summary, clinical history alone is an inaccurate predictor of AOM; therefore, examine the ears of a patient with any of the symptoms mentioned above, even if otoscopy in the previous 24–36 hours did not reveal an otitis media.
Diagnosis
The American Academy of Pediatrics and the American Academy of Family Physicians practice guidelines state that the diagnosis of AOM must meet the following three criteria: rapid onset, the presence of middle ear effusion (MEE), and signs and symptoms of middle ear inflammation.
Examine the tympanic membrane (TM) for shape (concave, retracted, bulging), color (pearly gray, injected, erythematous, yellow), the presence of landmarks (light reflex, malleus), and mobility. Redness alone is not sufficient to make the diagnosis, since crying can cause erythema of the drum. Perform pneumatic otoscopy, focusing on the light reflex. Decreased mobility of the tympanic membrane, which can be confirmed by tympanometry (flat tympanogram), is the most sensitive indicator of a middle ear effusion. A combination of erythema, bulging with or without a purulent effusion, loss of normal anatomic landmarks and decreased mobility are characteristic of an acute otitis media. Tympanic membrane perforation with recent onset of bloody or purulent ear discharge is also diagnostic. The history of a recent URI, complaints of ear pain, and constitutional symptoms such as listlessness and fever are insufficient to make the diagnosis without the typical otoscopic findings. See Table 6.1 for the differential diagnosis of otalgia.
| Diagnosis | Differentiating features |
|---|---|
| Acute myringitis | Inflammation of tympanic membrane |
| Bullae possible | |
| Dental abscess | Edema, erythema, or tenderness of gingiva |
| Otitis externa | Pain on traction of pinna, tenderness over tragus |
| Parotitis | Edema, tenderness over angle of mandible |
| Inflammation of Stensen’s duct | |
| Pharyngitis | Erythema, exudate, or herpangina on oropharyngeal examination |
| Serous otitis media | Dark, retracted tympanic membrane |
| Air-fluid level or bubbles behind tympanic membrane | |
| TMJ disease | Pain with palpation of TMJ, especially with mouth opening/closing |
The optimal position for examination varies with the age of the patient. Examine infants and young children supine on the table, restrained by an adult. Place an older child on the parent’s lap, seated face-to-face with the examiner. One of the parent’s arms can tightly embrace the child, while the other holds the patient’s head.
In some cases, there may be impacted cerumen in the ear canal obstructing the view of the tympanic membrane. Remove cerumen by curetting or irrigating with warm water 20 minutes after instilling several drops of hydrogen peroxide (if no tympanic membrane perforation is suspected).
ED Management
Despite the presence of an otitis media, perform a thorough physical examination to be certain that the patient does not have a more serious infection, such as meningitis. If the patient is toxic-appearing, admit for aggressive inpatient parenteral management.
The American Academy of Pediatrics practice guideline recommends a 48–72 hour period of observation, without antimicrobial treatment, for selected patients in whom follow-up can be assured if symptoms worsen (Table 6.2). See Table 6.3 for antibiotic choices and doses.
Table 6.2 Treatment guidelines for AOM by agea
| Age | With otorrheaa | Uni/bilaterala with severe symptomsb | Bilateral without otorrheaa | Unilateral without otorrheaa |
|---|---|---|---|---|
| 6 months – 2 years | Antibiotics | Antibiotics | Antibiotics | Antibiotics or additional observationc |
| ≥2 years | Antibiotics | Antibiotics | Antibiotics or additional observationc | Antibiotics or additional observationc |
a Applies only to patients with well-documented acute AOM.
b A toxic-appearing patient, otalgia for >48 hours, temperature >102 °F (38.9 °C) in the past 48 hours, or if follow-up is uncertain.
c If observation is offered a mechanism must be in place to ensure follow-up and begin antibiotics if the patient worsens or fails to improve within 48–72 hours.
| Antibiotic | Dose | Notes |
|---|---|---|
| Amoxicillin | 80–90 mg/kg/day div bid or tid | First choice if not penicillin-allergic |
| Amoxicillin-clavulanate ESa | 90 mg/kg of amoxicillin div q 12h | Use for treatment failure after 3 days |
| Azithromycin: first day | 10 mg/kg q day | Use for type 1 penicillin hypersensitivityb |
| days 2–5 | ||
| or | ||
| or | ||
| 5 mg/kg q day | ||
| 12 mg/kg × 5 days | ||
| 20 mg/kg/day × 3 days | ||
| Cefdinir | 14 mg/kg/day div q day or bid | Use for non-type 1 penicillin |
| hypersensitivity | ||
| Cefpodoxime | 10 mg/kg/day div q day or bid | Use for non-type 1 penicillin |
| hypersensitivity | ||
| Ceftriaxone IM | Unable to take PO: 50 mg/kg × 1 | |
| Treatment failure: 50 mg/kg/day × 3 | ||
| Cefuroxime | 30 mg/kg/day div q 12h | Non-type 1 penicillin hypersensitivity |
| Clarithromycin | 15 mg/kg/day div q 12h | Use for type 1 penicillin hypersensitivityb |
| Clindamycin | 20 mg/kg/day div tid or qid | Use for type 1 penicillin hypersensitivityb |
| Erythromycin-sulfisoxazole | 50 mg/kg/day of erythro div qid | Use for type 1 penicillin hypersensitivityb |
| Trimethoprim/sulfamethoxazole | 8–10 mg/kg of TMP div bid | Use for type 1 penicillin hypersensitivityb |
a Consider as first choice for otitis-conjunctivitis syndrome because of high prevalence of penicillinase resistance among non-typable H. flu (most common etiologic agent).
b Urticaria or anaphylaxis.
Regardless of the treatment option, pain management is critical. Use analgesics such as acetaminophen (15 mg/kg q 4h) or ibuprofen (10 mg/kg q 6h). In the ED, instilling a single dose of one to two drops of 2% viscous lidocaine may ameliorate extreme discomfort. Do not recommend antihistamine–decongestant combinations, which are of no benefit. Instruct the parents to return in 2–3 days if the child remains symptomatic (fever, ear pain, decreased hearing). If AOM is confirmed on re-examination, initiate antibiotic treatment. Patients whose symptoms are worsening at any time or who have continued symptoms at the completion of treatment require re-examination.
Under Two Months of age
Treat an afebrile, well-appearing infant <2 months of age with amoxicillin. However, if there is fever (>38.1 °C; 100.6 °F), toxicity, irritability, evidence of a systemic infection, a complicated neonatal course, or a previous hospitalization with antibiotic treatment, perform an evaluation for sepsis, treat with IV antibiotics, and admit the patient (see Evaluation of the Febrile Child, pp. 390–394).
A sterile effusion occurs in more than 40% of children following an AOM. This usually resolves without intervention, although a temporary conductive hearing loss can persist until the effusion resolves.
Tympanocentesis with culture is indicated for systemic toxicity, severe unremitting pain, inadequate response to conventional therapy, or a suppurative complication (facial nerve paralysis, mastoiditis, meningitis, brain abscess), and may be necessary in some immunocompromised patients. Obtain an otolaryngology consult.
Follow-up
Indications for Admission
Infant <1 month of age, with temperature over 38.1 °C (100.6 °F)
Toxic appearance
Immunocompromised patient with fever
Suppurative complication (mastoiditis, meningitis, brain abscess) or seventh nerve palsy
Bibliography
Cervical Lymphadenopathy
Palpable cervical lymph nodes >1 cm in diameter are present in approximately 80–90% of preschool and young, school-age children, especially if they have had a recent upper respiratory tract infection. Nonetheless, consider cervical lymphadenopathy in three broad etiologic categories: reactive, adenitis, or associated with systemic illness.
Clinical Presentation
Reactive
Most enlarged cervical lymph nodes are reactive, found in conjunction with a viral or bacterial infection of the head or neck. These nodes are generally benign and no work-up or specific treatment is necessary.
Most often the presentation reflects the primary illness (URI, pharyngitis, etc.). Other complaints include pain, a neck mass, stiff neck (unwillingness to move the neck side to side), or torticollis. Reactive nodes are usually multiple, discrete, firm, smaller than 1–2 cm in diameter, nontender, and mobile. The overlying skin is neither erythematous nor adherent. In general, reactive adenopathy subsides in 2–3 weeks, but it can persist.
Adenitis
An adenitis is an infection of the lymph node itself, most commonly (60–85%) caused by Staphylococcus aureus or group A Streptococcus, although viral and anaerobic infections have been implicated. Atypical Mycobacterium and Mycobacterium tuberculosis can result in a node with all the signs of acute infection. Cat scratch disease (Bartonellosis) may cause cervical, axillary, or inguinal adenitis.
With an adenitis, the node becomes enlarged, tender, and fluctuant. The overlying skin can be warm, erythematous, and occasionally adherent. The hallmarks of an atypical Mycobacterium infection are the presence of skin erythema overlying a nontender lymph node in an afebrile, otherwise well-appearing child. The node often suppurates. Cat scratch disease is characterized by a papule at the site of the scratch, followed in 5–60 days by regional lymphadenitis. Despite the impressive lymphadenopathy, the patient usually appears well, although 30% may have fever.
Systemic Disease
Systemic diseases, especially infectious mononucleosis and mono-like syndromes (cytomegalovirus, toxoplasmosis, leptospirosis, brucellosis, and tularemia), sarcoidosis, Kawasaki syndrome, and HIV can cause cervical as well as generalized lymphadenopathy. Some medications, such as phenytoin and isoniazid, can cause generalized lymphadenopathy. Always consider the possibility of a malignancy (leukemia, Hodgkin’s disease, non-Hodgkin’s lymphoma, neuroblastoma).
Mononucleosis and mono-like illnesses (pp. 425–427) can present with generalized tender lymphadenopathy, sometimes in association with an exudative pharyngitis, macular rash, and hepatosplenomegaly. These nodes are firm and mobile. Kawasaki disease (pp. 414–417) and HIV (pp. 396–399) are discussed elsewhere.
A malignant node is fixed, nontender, hard, and matted. It is frequently supraclavicular in location and may be described as persistent or continuously growing. Weight loss, weakness, pallor, night sweats, fever, petechiae, and ecchymoses are other possible findings.
Diagnosis
Perform a thorough examination of the head, neck, teeth, and gums to find a source of infection draining into the affected node(s). Weakness, fever, rash, hepatosplenomegaly, and generalized lymphadenopathy are all indicative of a systemic disease. See Table 6.4 for the differential diagnosis of cervical adenitis.
| Diagnosis | Differentiating features |
|---|---|
| Branchial cleft cyst | Smooth and fluctuant along the lower anterior border of SCM muscle |
| Cervical ribs | Bilateral, hard, immobile masses |
| Cystic hygroma | Soft, compressible |
| Usually transilluminates | |
| Dermoid cyst | Midline mass with calcifications on x-ray |
| Hemangioma | Present at birth |
| Red or bluish color | |
| Kawasaki | Nonpurulent conjunctivitis and mucous membrane changes |
| Polymorphic rash | |
| Edema of dorsum of extremities | |
| Malignancy | May have: weight loss, pallor, bleeding, fever, hepatosplenomegaly |
| Node is fixed, hard, matted, and persistent or growing | |
| Meningitis | Nuchal rigidity, photophobia, toxicity |
| Parotitis | Swelling obscures the angle of the jaw |
| Intraoral exam: edema, erythema, or drainage from Stensen’s duct | |
| Thyroglossal duct cyst | Midline mass between thyroid bone and suprasternal notch |
| Moves up when patient sticks out tongue |
There are seven features of the affected node(s) to consider.
Single or Multiple (Unilateral or Bilateral)
Enlargement of a single node generally occurs in an adenitis, although tuberculous adenitis causes bilateral involvement. Reactive adenopathy and systemic diseases most often result in multiple, bilateral involvement.
Location(s)
The location of a reactive node can suggest the site of the primary infection (preauricular–conjunctiva or external ear canal; occipital–scalp; submental and submandibular–intraoral). Supraclavicular adenopathy is suspicious for a malignancy, while occipital adenopathy suggests a viral illness (particularly roseola and rubella). Generalized lymphadenopathy most commonly occurs during mononucleosis or a mono-like infection, although leukemia is a possible etiology.
Size
Reactive nodes are typically small (<2 cm). Massive enlargement can occur with an atypical Mycobacterium infection.
Rate of Growth
Nodes that slowly enlarge suggest a malignancy, while rapid enlargement occurs in an infected or reactive node.
Mobility
In general, a freely movable node is benign. A node that is fixed to adjacent structures or matted to other nodes suggests a malignancy, mycobacterial infection, or cat scratch disease.
Consistency
Soft or firm nodes are benign, while fluctuance occurs in adenitis. A rubbery consistency is noted in sarcoidosis, and malignant nodes are usually rock hard.
Overlying Skin
Bacterial adenitis causes erythema and warmth of the overlying skin. However, adherence occurs in cat scratch disease and atypical Mycobacterium infection. A reactive node does not affect the overlying skin.
ED Management
Reactive
“Benign” reactive nodes found in conjunction with a head or neck infection require treatment of the primary illness only. If the pharynx is erythematous, obtain a rapid strep test or a throat culture. Benign nodes can be followed without intervention, although persistence for more than 4–6 weeks may indicate the need for further testing. Reassure the family and arrange for primary care follow-up.
Adenitis
When bacterial adenitis is diagnosed, obtain a throat culture or rapid strep test and give an oral antibiotic with staphylococcal and streptococcal coverage, such as amoxicillin-clavulanate (875/125 formulation; 90 mg/kg/day of amoxicillin div bid) or clindamycin (20 mg/kg/day div q 6h). Warm compresses, applied for 15–30 minutes every 3–4 hours, are a useful adjunct. Have the patient return in 2–3 days. If there is clinical improvement, or a positive strep test or culture, continue the antibiotics for a total of ten days. If the node has not responded to antibiotics and warm compresses, obtain an ultrasound and admit the patient for IV antibiotics. If, instead, the node has become fluctuant, also obtain an ultrasound and consult with an otolaryngologist or surgeon to arrange for an incision and drainage. Obtain Bartonella titers if the patient has had contact with a kitten.
Admit patients who are toxic or have nodes unresponsive to oral antibiotic therapy for parenteral treatment: nafcillin 150 mg/kg/day div q 6h, ampicillin-sulbactam (150 mg/kg/day div q 6h), or cefazolin 75 mg/kg/day div q 8h. Use clindamycin (40 mg/kg/day div q 6h) if MRSA is a concern. Obtain a CBC with differential, heterophile antibody, and a blood culture prior to starting intravenous therapy. Indications for a node biopsy include age greater than ten years, persistent and unexplained weight loss or fever, skin ulceration or fixation to the node, supraclavicular location, or continuously increasing size. If atypical mycobacterial infection is suspected, surgical curettage/excision is required as the infection is frequently resistant to antitubercular medication (pp. 428–429), but avoid incision and drainage, which can result in a chronic fistula. If tuberculosis is suspected because of possible exposure or travel, place a 5 TU PPD. If the PPD is positive, consider Mycobacterium as the cause of the infection. Obtain a chest x-ray and admit the patient for surgical consultation, collection of culture specimens, and institution of antituberculous therapy (pp. 435–439).
Systemic Disease
When a mononucleosis syndrome is suspected, obtain a heterophile antibody (≥5 years of age) or EBV titers (<5 years of age). Treatment is supportive. Note that the heterophile antibody may be negative early in the disease and in young or immunocompromised patients. If a malignancy is suspected, the initial evaluation includes a chest x-ray and CBC with differential and reticulocyte count prior to hematology consultation. See pp. 159–160 for the treatment of parotitis.
Indications for Admission
Cervical adenitis associated with toxicity or inadequate oral intake
Cervical adenitis unresponsive to outpatient treatment
Evaluation of a suspected malignancy
Institution of antituberculous therapy
Bibliography
Epistaxis
Epistaxis usually originates from the anterior nasal septum (Kiesselbach’s area). Trauma (nose picking, punch, fall), URIs, environmental allergies, excessive use of decongestants or topical nasal steroids, an overly dry environment, and foreign bodies are predisposing factors. Rarely, structural abnormalities (hemangioma, telangiectasia, or angiofibroma), a bleeding diathesis (usually thrombocytopenia), or hypertension is involved. While children are often rushed into the ED because of “massive” blood loss, clinically significant bleeding is unusual.
Clinical Presentation
Usually an anterior septal source is evident. It is rare for the bleeding to be bilateral, but blood crossing behind the nasal septum can mimic a bilateral bleed. Sometimes, if the site is posterior or if the child is sleeping, the blood may present as hematemesis.
Diagnosis
Examine the nasal cavity with the child sitting on the parent’s lap, using a bright light (otoscope). If a bleeding source is found, the examination may be terminated, as multiple sites are unusual, except in the case of a fractured nasal septum. If the patient has suffered nasal trauma, look for a septal hematoma, which appears as a bluish-black mass on the anterior septum, filling the nasal cavity. Occasionally, a mucosal hemangioma or telangiectasia is seen. If no cause is found, but blood is noted trickling down the throat, assume that there is a posterior source.
Examine the skin for hemangiomata or telangiectasias, which may also be present in the nasal cavity. Pallor, tachycardia, gallop rhythm, or orthostatic vital sign changes suggest significant blood loss. Jaundice, petechiae, purpura, lymphadenopathy, and hepatosplenomegaly may reflect a bleeding diathesis.
In general, no work-up is required for a nosebleed in an otherwise well child with an anterior septal source. Obtain a hematocrit if anemia is suspected, but evaluate for a bleeding diathesis (pp. 353–357) if the patient has any of the physical findings enumerated above, a long history of recurrent nosebleeds, easy bruising, hemarthrosis, multiple subconjunctival hemorrhages, or a family history of excessive bleeding.
ED Management
Most anterior bleeds respond to pressure. Pinch the nares together for a full five minutes with the child sitting upright leaning forward (to prevent swallowing of blood). If this is unsuccessful, soak gauze with 1:1000 aqueous epinephrine or 0.05% oxymetazoline solution and place it in the nasal cavity. Alternatively, if the bleeding remains brisk, pack the nose with petrolatum-impregnated gauze, merocel nasal packing, or Gelfoam. If the patient has recurrent bleeds, after hemostasis is obtained, apply topical anesthesia with 4% lidocaine or benzocaine and cauterize the site, if visible, for three seconds with a silver nitrate stick. Treat hemangiomata or telangiectasias in the same way, but do not use cautery if a bleeding diathesis is suspected (possible tissue slough). Humidification, saline nose drops during the day, and the application of petrolatum (Vaseline) to the septum at bedtime help reduce the recurrence of nose bleeds. If a nasal septal hematoma is suspected, consult an otolaryngologist for immediate drainage to prevent a septal abscess and subsequent nasal deformities.
If routine measures are ineffective or the source is posterior, either consult an otolaryngologist or place a posterior pack. Anesthetize the nose with a topical anesthetic (as above), insert a posterior nasal balloon pack (Epistat or Rapid Rhino, blow up the posterior balloon, pull anterior until it fits snugly in the nasopharynx, and then inflate the anterior balloon until the bleeding stops. Fill both balloons with saline solution. If nasal balloon packs are not available, pass an uninflated Foley catheter through the nose into the pharynx, inflate the balloon, and then pull the catheter back until it fits snugly posteriorly in the nose. Fill the nose with petrolatum-impregnated gauze up to the balloon and place a clamp across the catheter where it exits the nose. If an anterior or posterior nasal pack is placed, give the patient broad-spectrum antibiotics to prevent an acute sinusitis (see Table 6.3). Otolaryngology consultation is indicated.
Indications for Admission
Bilateral anterior pack
Posterior pack
Bleeding diathesis or significant blood loss
Bibliography
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