A 12-month-old girl is brought to the office due to 3 days of fever, rhinorrhea, and nasal congestion. The patient completed a course of oral antibiotics for an ear infection 3 weeks ago and was noted to have a persistent middle ear effusion at a well-child visit last week. There is no history of additional infections or medical conditions. She has no allergies. Both parents smoke cigarettes, and both older siblings received tympanostomy tubes as infants. Temperature is 39.4 C (102.9 F). The patient is irritable but easily consoled by her mother. External ear examination is unremarkable, and external ear canals are patent. Otoscopy shows bilateral bulging and pink tympanic membranes with poor mobility on insufflation. The oropharynx appears normal without lesions or sores, and the lungs are clear to auscultation. Which of the following is the most appropriate next step in management of this patient?

Question

A 12-month-old girl is brought to the office due to 3 days of fever, rhinorrhea, and nasal congestion.  The patient completed a course of oral antibiotics for an ear infection 3 weeks ago and was noted to have a persistent middle ear effusion at a well-child visit last week.  There is no history of additional infections or medical conditions.  She has no allergies.  Both parents smoke cigarettes, and both older siblings received tympanostomy tubes as infants.  Temperature is 39.4 C (102.9 F).  The patient is irritable but easily consoled by her mother.  External ear examination is unremarkable, and external ear canals are patent.  Otoscopy shows bilateral bulging and pink tympanic membranes with poor mobility on insufflation.  The oropharynx appears normal without lesions or sores, and the lungs are clear to auscultation.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d252_eee4_bc81_0f16ef5d71e3_MD0003_00 Acute otitis media (AOM) is common in children age 6-18 months because their eustachian tubes are straight and drain poorly. Risk factors include day care attendance, cigarette smoke exposure, and recent upper respiratory infection. Breastfed children have lower rates of AOM due to a relative decrease in bacterial colonization of the nasopharynx. Common pathogens include Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis. eustachian tubes Diagnosis is confirmed on otoscopy by visualization of a bulging tympanic membrane (TM) and/or the presence of middle ear effusion (indicated by poor TM mobility on insufflation) with TM inflammation (eg, erythema). Treatment with oral antibiotics is recommended in specific situations: otoscopy First-line therapy with amoxicillin is indicated for infants age <6 months and for children age ≥6 months with high fever (>39 C [102.2 F]), severe pain, or bilateral disease. Second-line therapy with amoxicillin-clavulanate is indicated for refractory symptoms after 2-3 days of antibiotic therapy or recurrent AOM (within 30 days) after antibiotic therapy. Therefore, this patient with high fever and recurrent, bilateral AOM after recent antibiotics warrants a course of oral amoxicillin-clavulanate. (Choice B) Ototopical antibiotic drops are used to treat otitis externa. Presentation includes ear pain and discharge with edema and inflammation of the external auditory canal. otitis externa (Choice C) Otitis media with effusion (middle ear fluid without TM inflammation) can be observed for resolution. Unilateral AOM accompanied by low-grade fever and mild pain can also be treated supportively and observed in patients age >6 months. This patient has bilateral AOM with a high fever, warranting treatment. (Choice D) Mastoiditis is a complication of AOM and presents with fever, ear pain, protrusion of the outer ear, and postauricular erythema and tenderness. Temporal CT scan may be indicated to confirm the diagnosis for atypical cases. This patient has an isolated AOM. (Choice E) Tympanocentesis and culture during tympanostomy tube placement should be considered for multiple episodes of AOM (eg, ≥3 episodes in 6 months) or persistent (>3 months) middle ear effusion with hearing loss. This patient's infection does not warrant invasive intervention. (Choice F) Although viral upper respiratory infections often precede AOM, nasopharyngeal PCR testing is not indicated because viral identification does not preclude a secondary bacterial infection and therefore does not change management. Educational objective: Oral antibiotics for acute otitis media should be administered to children with high fever, severe pain, or bilateral disease. Amoxicillin is first-line therapy, and amoxicillin-clavulanate is indicated for persistent or recurrent infection. 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)

A 12-Month-Old Girl Is Brought to the Office Due to 3