An 18-month-old boy is brought to the office for right ear pain. About 4 weeks ago, he had fever and right ear pain and was prescribed a 10-day course of high-dose amoxicillin for acute otitis media; he completed the course and had a normal follow-up visit 2 weeks ago. While on the medication, he experienced improvement in his symptoms. For the past 3 days, he has been tugging on his right ear and crying; he developed fever today. He has no nasal congestion, neck stiffness, cough, emesis, or other symptoms. He is otherwise healthy and takes no medications. His immunizations are up to date. Temperature is 38.5 C (101.3 F), blood pressure is 108/66 mm Hg, pulse is 96/min, and respirations are 21/min. Physical examination demonstrates an alert, uncomfortable child. Pupils are equal and reactive; the conjunctivae are injected bilaterally and have purulent discharge. There is no rhinorrhea or sinus tenderness. The external ears appear normal and are not painful to manipulation; there is no drainage in the external canal. The right tympanic membrane is erythematous, bulging, and immobile on pneumatic air insufflation. The left tympanic membrane appears normal. Both mastoids are nontender and nonerythematous. The neck is nontender and has full range of motion. Cardiopulmonary examination is normal. An appropriate diagnosis is made, and the treatment options are discussed with the patient's mother. What is the most appropriate next step in management of this boy's condition?

Question

An 18-month-old boy is brought to the office for right ear pain.  About 4 weeks ago, he had fever and right ear pain and was prescribed a 10-day course of high-dose amoxicillin for acute otitis media; he completed the course and had a normal follow-up visit 2 weeks ago.  While on the medication, he experienced improvement in his symptoms.  For the past 3 days, he has been tugging on his right ear and crying; he developed fever today.  He has no nasal congestion, neck stiffness, cough, emesis, or other symptoms.  He is otherwise healthy and takes no medications.  His immunizations are up to date.  Temperature is 38.5 C (101.3 F), blood pressure is 108/66 mm Hg, pulse is 96/min, and respirations are 21/min.  Physical examination demonstrates an alert, uncomfortable child.  Pupils are equal and reactive; the conjunctivae are injected bilaterally and have purulent discharge.  There is no rhinorrhea or sinus tenderness.  The external ears appear normal and are not painful to manipulation; there is no drainage in the external canal.  The right tympanic membrane is erythematous, bulging, and immobile on pneumatic air insufflation.  The left tympanic membrane appears normal.  Both mastoids are nontender and nonerythematous.  The neck is nontender and has full range of motion.  Cardiopulmonary examination is normal. An appropriate diagnosis is made, and the treatment options are discussed with the patient's mother.  What is the most appropriate next step in management of this boy's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfb4_5643_8f63_996a927bec31_MD0005_00 Uncomplicated acute otitis media (AOM) should be treated empirically with a 10-day course of high-dose amoxicillin (Choice B). However, repeat infection within a month of initial treatment is concerning for beta-lactamase-producing strains of nontypeable Haemophilus influenzae, Streptococcus pneumoniae, or Moraxella catarrhalis. Amoxicillin-clavulanic acid, which has the benefit of an added beta-lactamase inhibitor, is the preferred treatment for recurrent AOM if the patient has already received amoxicillin within the same month. (Choice A) Myringotomy and placement of tympanostomy tubes is not appropriate after a single recurrence. If a patient has experienced persistent treatment failure, has persistent effusion for >3 months, or has >3 episodes of AOM in 6 months (or >4 in a year), this procedure may be considered. Myringotomy and placement of tympanostomy tubes (Choice D) Ototopical antibiotics are indicated for the treatment of otitis externa. They are not recommended for the treatment of AOM, even if there is tympanic membrane perforation, except for infections that occur in the setting of tympanostomy tubes. (Choice E) Tympanocentesis (ie, fluid drainage from middle ear) with Gram stain, culture, and antibiotic susceptibility testing should be considered in children with multiple treatment failures. However, this procedure is invasive and unnecessary for most cases of AOM that resolve with 1 or 2 empiric antibiotic treatment courses. Educational objective: Uncomplicated acute otitis media (AOM) should be treated empirically with high-dose oral amoxicillin. Recurrent AOM should raise concern for beta-lactamase resistance and warrants treatment with amoxicillin-clavulanic acid. Tympanocentesis and tympanostomy are reserved for persistent treatment failure despite appropriate antimicrobial therapy. References: Otitis media: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/24134083) The diagnosis and management of acute otitis media. (http://www.ncbi.nlm.nih.gov/pubmed/23439909)

An 18-Month-Old Boy Is Brought to the Office for Right