1

A 3-year-old female patient presents to your urgent care center with a 2-day history of fever and right ear pain. What are the common causes of ear pain?

The most common causes of ear pain in children are acute otitis media (AOM), acute otitis externa (AOE), acute mastoiditis, and foreign bodies in the ear.

2

How common are ear infections in children?

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  Ear infections are the second most common diagnosis in children after upper respiratory infections (URIs).

  
  
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  Peak incidence of AOM occurs in the first 2 years.

  
  
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  Approximately 90% of children will have developed at least one episode of AOM by the age of 7 years.

3

Why are children more prone to ear infections?

Children’s eustachian tubes are shorter and more horizontal than adults’, making it easier for viruses and bacteria to reach the middle ear. Additionally, adenoids may be enlarged in children and obstruct drainage of the eustachian tube.

4

What other risk factors contribute to ear infections?

Preceding URI, secondhand smoking, bottle feeding, and daycare attendance. AOM is also more common in the winter in temperate climates. Children who experience their first AOM within the first year of life are also more predisposed to recurrent AOM in the future.

5

What are the common forms of ear infections?

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  Acute otitis externa: Inflammation or infection of the external ear canal, also known as “swimmer’s ear” or “tropical ear.”

  
  
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  Acute otitis media: Inflammation or infection of the middle ear.

6

Why does acute otitis externa occur?

AOE occurs when there are changes in the canal environment that lead to a change in pH balance from acidic to basic as well as increase in moisture. This typically creates a break in the skin of the external ear canal that promotes the growth of bacteria and subsequent infection.

7

What are the manifestations of AOE?

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  Itching of the ear.

  
  
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  Tenderness with pulling and pressure on the pinna.

  
  
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  Tender, erythematous, and edematous ear canal.

  
  
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  Ear discharge, from clear, odorless to seropurulent, foul smelling.

  
  
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  Tender periauricular and preauricular lymph nodes.

8

How do you treat AOE?

The vast majority of AOE is caused by bacteria, with a mix of gram-positive and gram-negative microorganisms. Fungi is rarely the cause for AOE. Therefore, treatment should be geared toward covering for these, including pseudomonas (i.e., ofloxacin ear drops).

9

What are the most common pathogens in bacterial AOM?

Despite the advent of more effective vaccines, microbiological results from middle ear effusion continue to yield positive for Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis.

10

What are the diagnostic criteria for AOM in children?

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  Infants with AOM may present with fever, upper respiratory symptoms (nasal congestion and cough), irritability, decreased appetite, and vomiting, while children and adolescents present with similar symptoms and complaints of significant unilateral or bilateral ear pain.

  
  
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  AOM should be diagnosed in children who present with

  
  
  
  
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    Moderate to severe bulging of tympanic membrane (TM).

    
    
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    New onset otorrhea not due to otitis externa.

    
    
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    Decreased TM mobility observed on pneumatic insufflation.

  
  
  
  
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  AOM may be diagnosed in children who present with

  
  
  
  
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    Mild bulging of the TM and <48 hours of otalgia (holding, tugging, or rubbing of the ear in a nonverbal child) or intense erythema of the TM.

  
  

11

When should AOM be treated with antibiotics?

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  Antibiotics should be prescribed for AOM (bilateral or unilateral) in children 6 months and older with severe signs or symptoms (moderate to severe otalgia, or otalgia >48 hours, or temperature >39°C).

  
  
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  Amoxicillin (80–90 mg/kg per day divided in two doses) is the antibiotic of choice for AOM.

  
  
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  Although there is no consensus on duration of therapy, most experts recommend a longer course (10 days) for children younger than 24 months, and possibly a shorter course (3, 5, or 7 days, pick your choice) in well-appearing, uncomplicated cases of AOM in older children. In reality, most guardians will discontinue antibiotics when their child is feeling better.

12

When is amoxicillin/clavulanic acid preferred for AOM?

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  Amoxicillin was used within the last 30 days for AOM, or

  
  
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  Patient has concomitant purulent conjunctivitis, or

  
  
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  Patient has history of recurrent AOM unresponsive to amoxicillin.

Recommended dose for amoxicillin/clavulanate is 90 mg/kg per day divided in two doses.

Change in antibiotic therapy (po cefdinir, cefuroxime, cefpodoxime, clindamycin, or ceftriaxone 50 mg IM per day for 1–3 days) is suggested if the child’s symptoms have worsened or failed to respond to the initial antibiotic treatment within 48–72 hours.

13

Is there a role for “watchful waiting”?

Yes.

For children ages 6–23 months with unilateral AOM without severe signs or symptoms (mild otalgia for <48 hours and temperature <39°C).

For children ages 24 months and older with bilateral or unilateral AOM without severe signs or symptoms (mild otalgia for <48 hours and temperature <39°C).

When observation is used, a mechanism should be in place to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48–72 hours of onset of symptoms.

14

How should you treat an AOM in the presence of (a) a tympanic membrane perforation, or (b) tympanostomy tubes?

In both scenarios, since there is a direct conduit to the middle ear, otic topical antibiotic drops are recommended. Due to potential for ototoxicity, polymyxin B drops are not recommended. In the case of recurrent otorrhea, institution of oral antibiotics and referral to otolaryngology to obtain a culture is recommended. Note that an AOM with a healing or completely healed TM perforation or tympanostomy tube that is occluded with cerumen or purulent drainage may require the addition of oral antibiotics.

15

In addition to antibiotics, how should otalgia be treated in children?

Analgesics (acetaminophen, ibuprofen). Topical agents (benzocaine, procaine, or lidocaine in children over 5 years of age, amethocaine/phenazone drops in children over 6 years of age).

16

A 5-year-old male patient presents to your urgent care center with a 5-day history of increasing bilateral ear pain and a 2-day history of left ear swelling. His mother did an internet search and asks you whether this is mastoiditis. What are the common manifestations of mastoiditis?

Mastoiditis is an infection resulting from extension of an AOM.

The most common organisms associated with mastoiditis include S. pneumoniae, S. pyogenes, and S. aureus.

The most common signs and symptoms include fever; unilateral ear pain; postauricular swelling, erythema, and tenderness; the involved pinna is deviated outward and rotated forward; the tympanic membrane is often described as bulging, immobile, and opaque.

Diagnosis is made by computed tomography (CT) scan of the head (destruction of mastoid air cells, with or without abscess). Fluid-filled air cells without bony destruction are insufficient to make the diagnosis of mastoiditis.

17

Can mastoiditis be treated as an outpatient?

No. A CT scan of the head demonstrating destruction of mastoid air cells, with or without abscess, requires hospitalization for intravenous antibiotics (IV ampicillin-sulbactam or ceftriaxone for 3–4 weeks, then switching to oral antibiotics, such as Augmentin, levofloxacin, or clindamycin, with clinical improvement). Mastoidectomy, with myringotomy +/− tympanostomy tubes, is indicated if no clinical improvement is seen within 48 hours of antibiotic initiation, or if there is concern for subperiosteal abscess, facial nerve palsy, brain abscess, or meningitis.