A 3-year-old boy is brought to the office due to ear drainage. His mother reports that he was well until the previous day, when he developed a fever of 38.9 C (102 F), accompanied by crankiness, decreased appetite, and frequent crying. He was given acetaminophen for his symptoms, but they did not improve. Today his mother put him in his room for a nap; when she returned, thick white liquid was leaking from his right ear. Since waking from his nap, he has not been cranky, but the drainage has persisted. Temperature is 38.3 C (101 F), pulse is 114/min, and respirations are 18/min. On physical examination, he appears alert and active. The pupils are equal and reactive; the nasal turbinates are clear, and there is no erythema or exudate in the pharynx. The left tympanic membrane is normal, but the right tympanic membrane is not visible due to copious purulent drainage in the canal. The pinna appears normal and there is no tenderness on manipulation of the ear. The neck is supple without lymphadenopathy. Cardiopulmonary examination is within normal limits. What is the most likely explanation for this patient's findings?
A)Bacterial otitis externa
B)Necrotizing otitis externa
C)Serous otitis media
D)Superinfected foreign body
E)Suppurative otitis media

Question

A 3-year-old boy is brought to the office due to ear drainage.  His mother reports that he was well until the previous day, when he developed a fever of 38.9 C (102 F), accompanied by crankiness, decreased appetite, and frequent crying.  He was given acetaminophen for his symptoms, but they did not improve.  Today his mother put him in his room for a nap; when she returned, thick white liquid was leaking from his right ear.  Since waking from his nap, he has not been cranky, but the drainage has persisted.  Temperature is 38.3 C (101 F), pulse is 114/min, and respirations are 18/min.  On physical examination, he appears alert and active.  The pupils are equal and reactive; the nasal turbinates are clear, and there is no erythema or exudate in the pharynx.  The left tympanic membrane is normal, but the right tympanic membrane is not visible due to copious purulent drainage in the canal.  The pinna appears normal and there is no tenderness on manipulation of the ear.  The neck is supple without lymphadenopathy.  Cardiopulmonary examination is within normal limits.  What is the most likely explanation for this patient's findings?
A)Bacterial otitis externa
B)Necrotizing otitis externa
C)Serous otitis media
D)Superinfected foreign body
E)Suppurative otitis media

Quizplus · Accepted Answer

Explanation: 11ec2b69_c12d_893c_8f63_21c926de5e75_MD0005_00 This patient had fever and crankiness followed by purulent drainage from his ear. The tympanic membrane is obscured by otorrhea, and there is no tenderness to manipulation of the pinna. This is a classic presentation of suppurative otitis media (also called acute otitis media or bacterial otitis media) with tympanic membrane perforation. Suppurative otitis media occurs when fluid in the middle ear cavity is infected by bacteria from the nasopharynx. Infection creates pressure on the tympanic membrane, causing it to bulge. If the condition is untreated, in some cases the pressure will cause the membrane to rupture, leaking purulent fluid. Often (as in this case), membrane rupture relieves pressure and some of the patient's pain, with improvement in symptoms such as crankiness. Tympanic membrane perforation can occur during an episode of otitis media caused by any organism, but it is most common in those caused by group A Streptococcus. (Choice A) Bacterial otitis externa is an infection of the outer auditory canal usually caused by Pseudomonas aeruginosa. Although it does result in ear pain and purulent ear drainage, fever is generally absent, pain on manipulation of the ear is almost always present, and episodes generally follow water exposure. (Choice B) Necrotizing ("malignant") otitis externa is an aggressive Pseudomonas infection of the external ear canal that invades the neighboring skull bone. Fever, pain, and purulent drainage are expected; however, this diagnosis occurs almost exclusively in elderly patients with diabetes and in immunocompromised individuals. (Choice C) Serous otitis media occurs when an effusion is present in the middle ear canal in the absence of infection and inflammation. It typically follows episodes of suppurative otitis media, but it is not associated with fever, pain, crankiness, tympanic membrane rupture, or purulent drainage. Serous otitis media (Choice D) An otic foreign body may be encountered in young children (age <6) and may present with ear drainage; however, superinfection and fever are uncommon, copious drainage is rare, and the object is typically visualized on otoscopic examination. Educational objective: Suppurative otitis media is typically accompanied by fever, pain, and crankiness, and if untreated can be followed by tympanic membrane perforation, acute purulent otorrhea in the external auditory canal, and reduction in pain after membrane rupture. Pain is usually absent on manipulation of the pinna.

A 3-Year-Old Boy Is Brought to the Office Due to Ear