A 2-year-old girl is brought to the office due to drainage from the left ear. The patient has been irritable over the past few days, and this morning, her mother noticed foul-smelling drainage on her pillow. Three weeks ago, the patient was treated with amoxicillin for an episode of acute otitis media. Temperature is 37.9 C (100.2 F); all other vital signs are normal. On examination, the left external ear is unremarkable except for some dried, crusted drainage at the entrance of the external canal. Otoscopic examination reveals a perforated, erythematous left tympanic membrane with a small amount of purulent drainage. Which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 2-year-old girl is brought to the office due to drainage from the left ear.  The patient has been irritable over the past few days, and this morning, her mother noticed foul-smelling drainage on her pillow.  Three weeks ago, the patient was treated with amoxicillin for an episode of acute otitis media.  Temperature is 37.9 C (100.2 F); all other vital signs are normal.  On examination, the left external ear is unremarkable except for some dried, crusted drainage at the entrance of the external canal.  Otoscopic examination reveals a perforated, erythematous left tympanic membrane with a small amount of purulent drainage.  Which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

11ec25c8_d6ca_94c7_bc81_2dc4b2cb3308_MD0003_00 This patient has otorrhea with an inflamed and perforated tympanic membrane (TM), findings consistent with acute otitis media (AOM) with perforation. The most common pathogens causing AOM are Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis. Group A Streptococcus is less commonly implicated in AOM alone but is often associated with AOM with perforation. Symptoms of AOM may include acute otalgia, irritability, and fever. Physical examination typically reveals a bulging TM and/or the presence of middle ear effusion with TM erythema. In a minority of cases, increased middle ear pressure can cause localized ischemia and TM perforation, resulting in drainage of purulent material (ie, otorrhea), as seen in this patient. Otalgia classically improves following rupture due to the abrupt relief of middle ear pressure. TM perforation First-line therapy for AOM with or without TM perforation is amoxicillin. However, due to increased risk of beta-lactam resistance, amoxicillin-clavulanate is indicated for a patient who has been treated with amoxicillin within the past 30 days, as in this case. Perforation can lead to temporary conductive hearing loss, but the TM typically heals spontaneously within days; surgical correction may be required for perforation lasting several months. (Choices B and E) Azithromycin and trimethoprim-sulfamethoxazole (TMP-SMX) can be used to treat AOM in penicillin-allergic patients. However, Streptococcus pneumoniae is often resistant to macrolides, making azithromycin a suboptimal empiric antibiotic choice. Likewise, group A Streptococcus (common in TM perforation) is typically resistant to TMP-SMX, so it should not be used in this patient. (Choice C) Oral fluoroquinolones (eg, ciprofloxacin) are generally avoided in children due to the risk of tendinopathy. Ciprofloxacin otic drops can be used to treat AOM with otorrhea in a child with tympanostomy tubes. However, because TM perforations in a patient without tubes (such as this patient) typically close rapidly, oral antibiotics are indicated. (Choice D) Fluconazole can be considered for refractory otitis externa caused by fungal infection. Symptoms include ear pain/itching and otorrhea. TM perforation is not associated with otitis externa. (Choice F) Vancomycin treats mastoiditis, which classically presents with otalgia, fever, and postauricular erythema and tenderness with outward displacement of the outer ear. This patient's external ear examination is normal. Educational objective: Acute otitis media with tympanic membrane (TM) perforation typically presents with acute otalgia, otorrhea, and an erythematous and perforated TM. Amoxicillin is first-line therapy; amoxicillin-clavulanate is indicated in a patient who has received amoxicillin within the past 30 days. References: Acute otitis media. (http://www.ncbi.nlm.nih.gov/pubmed/29262176)

A 2-Year-Old Girl Is Brought to the Office Due to Drainage