A 2-year-old boy is brought to the office for evaluation of right ear pain. Two days ago, his mother saw him put a small rock in his ear while he was playing outside. She pulled it out and rinsed his ear thoroughly with soapy water in the bath that evening. The patient had no pain that night, but the next morning he woke up crying and pulling on his ear. He has been fussy and has not slept well since then. The patient has had 2 previous episodes of acute otitis media that resolved with antibiotics. Immunizations are up to date. Temperature is 37 C (98.6 F), blood pressure is 90/50 mm Hg, and pulse is 100/min. Examination shows a somewhat anxious child. There is no rhinorrhea. Physical examination of the oropharynx shows normal tonsils with no exudate or erythema. There is no cervical adenopathy. The patient cries during examination of the right ear, which reveals a tender, swollen ear canal. Although only a part of the tympanic membrane is seen, it appears normal. The left ear is normal. Which of the following is the most appropriate treatment for this patient's condition?

Question

A 2-year-old boy is brought to the office for evaluation of right ear pain.  Two days ago, his mother saw him put a small rock in his ear while he was playing outside.  She pulled it out and rinsed his ear thoroughly with soapy water in the bath that evening.  The patient had no pain that night, but the next morning he woke up crying and pulling on his ear.  He has been fussy and has not slept well since then.  The patient has had 2 previous episodes of acute otitis media that resolved with antibiotics.  Immunizations are up to date.  Temperature is 37 C (98.6 F), blood pressure is 90/50 mm Hg, and pulse is 100/min.  Examination shows a somewhat anxious child.  There is no rhinorrhea.  Physical examination of the oropharynx shows normal tonsils with no exudate or erythema.  There is no cervical adenopathy.  The patient cries during examination of the right ear, which reveals a tender, swollen ear canal.  Although only a part of the tympanic membrane is seen, it appears normal.  The left ear is normal.  Which of the following is the most appropriate treatment for this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d5f4_7f70_bc81_d1a5cecbba93_MD0003_00 This child with ear pain and a swollen external auditory canal (EAC) after trauma and water exposure has acute otitis externa ("swimmer's ear"). At least half of all cases occur in children and adolescents. Water exposure is a frequent antecedent because it can alter the ear canal pH, cause maceration of the skin, and introduce bacteria into the ear canal. Trauma (eg, the rock in this patient's ear) can also increase the risk for otitis externa. Pseudomonas aeruginosa is the most common pathogen in otitis externa and must be covered with empiric treatment regimens. Staphylococcus aureus, the second most common pathogen, is typically covered by antipseudomonal antibiotics (eg, fluoroquinolones). Topical therapy (eg, ciprofloxacin [± glucocorticoid] drops) is appropriate for uncomplicated otitis externa; antibiotic resistance is unlikely due to the high antibiotic concentration delivered to the site of infection. If the canal is too swollen, wick placement is used to facilitate drug delivery. Although systemic fluoroquinolone administration in children is limited due to adverse effects, topical fluoroquinolones are well tolerated. (Choice A) Oral amoxicillin/clavulanic acid is used for otitis media when there is concern for amoxicillin resistance (eg, recent beta-lactam therapy). Otitis media may present with ear pain but would cause a bulging tympanic membrane. P aeruginosa is not susceptible to amoxicillin/clavulanic acid. (Choices B and F) Fungal otitis (otomycosis) occurs most commonly after treatment for acute otitis externa. It is more common in individuals with chronically moist ear canals (eg, those with hearing aids, especially in warm, humid climates). Examination of the EAC shows whitish fungal debris with fruiting bodies or spores. Management is debridement and topical (eg, clotrimazole), rather than oral (eg, fluconazole), antifungal therapy. Nystatin is not typically used for fungal otitis. (Choices C and E) Trimethoprim-sulfamethoxazole and clindamycin should not be used for empiric therapy of otitis externa; although they cover S aureus, they do not cover P aeruginosa. In addition, this patient has no indication for systemic therapy. Educational objective: Otitis externa ("swimmer's ear") is characterized by pain, erythema, and edema of the external auditory canal. It frequently occurs after water exposure or trauma to the canal. Topical antipseudomonal treatment is appropriate unless complicated by diabetes mellitus, HIV, or infection that has spread beyond the external auditory canal. References: Clinical practice guideline: acute otitis externa. (http://www.ncbi.nlm.nih.gov/pubmed/24491310)

A 2-Year-Old Boy Is Brought to the Office for Evaluation