Rosen & Barkin's 5-Minute Emergency Medicine Consult (500 page)

Cultures unhelpful unless done by tympanocentesis

CT scan if associated mastoiditis is suspected

• Tympanocentesis—indications:
  
  • Severe pain or toxicity
    
  • Failure of antimicrobial therapy
    
  • Suspicion of suppurative complication
    
  • Sick neonate
    
  • Immunocompromised patient
    
• Tympanometry and acoustic otoscopy may be useful with difficult exams
  

• Infection:
  
  • Otitis externa
    
  • Mastoiditis
    
  • Dental abscess
    
  • Allergic rhinitis
    
  • Cholesteatoma
    
  • Peritonsillar abscess
    
  • Sinusitis
    
  • Lymphadenitis
    
  • Parotitis
    
  • Meningitis
    
• Trauma:
  
  • Perforation of the TM
    
  • Foreign body in ear
    
  • Barotrauma
    
  • Instrumentation
    
• Serous OM or eustachian tube dysfunction
  
• Impacted ear cerumen
  
• Impacted 3rd molar
  
• Temporomandibular joint dysfunction
  

TREATMENT

• Most mild cases could resolve without antibiotics
  
• Antibiotics are indicated for:
  
  • All infants <6 mo
    
  • Children <2 yr with bilateral OM
    
  • Bilateral OM in kids <2 yr
    
  • Children >6 mo with severe infection (otalgia for >48 hr or temperature 102.2°F or higher)
    
  • Bilateral OM in kids <2 yr
    
  • Children >6 mo with ruptured TM with drainage
    
• For otherwise normal healthy patients ≥6 mo with mild symptoms and/or uncertain diagnosis, consider no antibiotics and repeat evaluation in 2–3 days:
  
  • For reliable parents, may provide a prescription for oral antibiotics, which the family can fill if the child’s symptoms get worse or persist after 2 days
    
• Considerations should include recurrent nature of OM, lack of clinical response, and resistance patterns in community
  
• Parenteral antibiotics are indicated in febrile toxic children <1 yr or with immunocompromise
  
• Antihistamines, decongestants, and steroids have no proven efficacy
  
• Antipyretics and analgesics are important (avoid local analgesics in perforated TMs)
  

• Antibiotics:
  
  • Amoxicillin: 500–875 mg PO q12h (peds: 80–90 mg/kg/d PO div. q12h) for 10 days
    
  • Amoxicillin–clavulanic acid: 500–875 mg PO q12h (peds: 90 mg/kg/d PO q12h) for 10 days
    
  • Azithromycin: 10 mg/kg PO day 1, then 5 mg/kg/d PO days 2–5
    
  • Cefuroxime: 500 mg PO q12h (peds: 30 mg/kg/d PO div. q12h)
    
• Analgesia:
  
  • Acetaminophen: 500 mg PO q6h (peds: 15 mg/kg per dose orally/rectally every 4–6 hr); not to exceed 4 g/24 h
    
  • Antipyrine/benzocaine (5.4%/1.4% solution): 2–4 drops in ear QID PRN
    
  • Ibuprofen: 400–600 mg PO q6–8h (peds: 10 mg/kg per dose orally every 6 hr)
    

FOLLOW-UP

Febrile toxic children who are:

• <1 yr, immunocompromised
  
• Moderately or severely dehydrated
  
• Unable to tolerate oral fluids or medications
  
• Suspected or proven associated significant infection
  
• Suspected abuse
  
• Unreliable caretaker
  

Children without any of the aforementioned criteria

• Follow-up in 10–14 days to ensure resolution
  
• Indications for earlier follow-up:
  
  • Child does not get better in 24–48 hr
    
  • Any progression of signs or symptoms
    
  • New problems develop, including a rash
    
  • Any concerns arise
    

• Recurrent OM:
  
  • 3 episodes within 6 mo or
    
  • 4 episodes in 1 yr with the last within 6 mo
    
• Perforated TM
  
• Serous OM
  
• Hearing loss (conductive and sensorineural)
  
• Facial nerve injury
  
• Mastoiditis
  
• Cholesteatoma
  
• Meningitis
  
• Subdural empyema
  
• Labyrinthitis
  
• Epidural abscess
  
• Venous sinus thrombosis
  

For otherwise normal healthy patients ≥6 mo with mild symptoms and/or uncertain diagnosis, consider no antibiotics and repeat evaluation in 2–3 days.

• American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media.
  Pediatrics
  . 2004;113:1451–1465.
  
• Coker TR, Chan LS, Newberry SJ, et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: A systematic review.
  JAMA.
  2010;304:2161–2169.
  
• Fischer T, Singer AJ, Lee C, et al. National trends in emergency department antibiotic prescribing for children with acute otitis media, 1996–2005.
  Acad Emerg Med
  . 2007;14:1172–1175.
  
• Greenberg D, Hoffman S, Leibovitz E, et al. Acute otitis media in children: Association with day care centers–antibacterial resistance, treatment, and prevention.
  Paediatr Drugs.
  2008;10:75–83.
  
• Gunasekera H, Morris PS, McIntyre P, et al. Management of children with otitis media: A summary of evidence from recent systematic reviews.
  J Paediatr Child Health
  . 2009;45:554–562.
  
• Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media.
  Pediatrics
  . 2013;131:e964–e999.
  
• Powers JH. Diagnosis and treatment of acute otitis media: Evaluating the evidence.
  Infect Dis Clin North Am
  . 2007;21:409–426.
  
• Spiro DM, Arnold DH. The concept and practice of a wait-and-see approach to acute otitis media.
  Curr Opin Pediatr
  . 2008;20:72–78.
  

CODES

• 381.4 Nonsuppurative otitis media, not specified as acute or chronic
  
• 381.60 Obstruction of Eustachian tube, unspecified
  
• 382.9 Unspecified otitis media
  

BASICS

• Ear cartilage has no blood supply and isnutritionally dependent on perichondrium
  
• Hematomas often disrupt perichondrium and cartilage
  
  • Can lead to:
    
    • Ischemia
      
    • Perichondritis
      
    • Necrosis
      
    • Cauliflower ear
      
• Penetrating injuries or bite wounds may lead to infection of cartilage
  

• Air-space cavity containing ossicles; susceptible to injuries disrupting pressure (blast, diving)
  
• Bordered by medial cranial fossa (including temporal and mastoid bones)
  
• Traumatic fractures can lead to CSF leak (otorrhea/rhinorhea)
  
  • May disrupt enclosed vestibular system
    
• Facial nerve passes through cavity—injury to cavity may cause peripheral nerve paralysis
  

• Blunt trauma:
  
  • Contact sports such as wrestling
    
  • Motorcycle helmets
    
• Penetrating trauma such as tympanic membrane (TM) perforation from cotton swabs
  
• Human or animal bites
  
• Blast injury
  
• Lightning injury:
  
  • TM and ossicular disruptions occur in 50% of lightning strikes
    
• Chemical exposure
  
• Thermal injury
  
• Diving injuries:
  
  • Inner ear barotrauma
    
  • TM rupture
    

Consider nonaccidental trauma

DIAGNOSIS