Pediatric emergency medicine trisk 282

water-resistant, acidic, antibacterial substance that prevents maceration.
Swimmers ear develops when water in the ear disrupts the protective cerumen
layer. Disruption of the cerumen layer may occur in attempts to remove water in
the canal or to relieve pruritus. Insertion of cotton swabs or other objects may
cause injury, creating portals of entry for bacteria in the external ear. Ear pain and
sometimes visible ear discharge are the usual symptoms of otitis externa.
Examination reveals an erythematous, swollen external canal filled with debris or
purulence. Traction on the auricle causes pain with otitis externa, a finding that
can help distinguish it from otitis media with perforation. Gentle removal of
debris, instillation of topical antibiotics, and systemic analgesia are the usual
treatment. When swelling is so severe that topical antibiotics may not reach the
more proximal portion of the canal, a wick may be inserted to facilitate antibiotic
entry. Systemic antibiotics are indicated if there is extensive cellulitis spreading
beyond the external canal. Otitis externa is usually polymicrobial, but S. aureus
and P. aeruginosa are important pathogens to cover, and polymyxin/neomycin or
fluoroquinolone otic drops are the preferred treatment. Otitis externa with P.
aeruginosa can be fulminant and necrotizing. Recalcitrant cases of otitis externa,
especially if pruritus is a prominent symptom, may require evaluation for fungal
disease (otomycoses) or deeper infection.

FIGURE 58.1 Ear pain algorithm. AOM, acute otitis media; CNS, central nervous system;
TMJ, temporomandibular joint; OME, otitis media with effusion.

ACUTE OTITIS MEDIA


AOM is the most common illness prompting office visits and antimicrobial
prescriptions in childhood. Clinical practice guidelines have encouraged a stricter
diagnostic threshold for AOM, and immunization with PCV7 and influenza
vaccines may have reduced the actual incidence.
AOM is defined as the rapid onset of signs and symptoms of inflammation in

the middle ear. It is considered severe if there is moderate to severe otalgia or
fever >39°C (102.2°F). Aside from ear pain, reported in only 50% to 60% of
children with AOM, symptoms of AOM such as irritability, ear tugging, sleep
disruption, and fever are variable and nonspecific. Using strict but appropriate
otoscopic criteria, a majority of children whose parent suspects AOM in fact have
uncomplicated upper respiratory infection (URI).
Examination of the TM is one of the most difficult clinical skills to master.
Agreement on AOM diagnosis between otolaryngologists, the gold standard, and
pediatricians or family physicians is abysmal. Improved training in the diagnosis
of AOM and careful physical examination is clearly warranted.
In younger children with respiratory symptoms, fever, or specific ear
symptoms, adequate visualization of the TM is required. Despite the increasing
pressure to manage and make a disposition for patients quickly, clinicians must
take the time to accurately determine if AOM is present. Removal of cerumen
with saline irrigation, peroxide-containing ear drops, docusate sodium syrup,
and/or curettage will be a frequent procedure for clinicians caring for children.
Immobilization of the uncooperative child may be required and proper equipment
must be available.
Bulging of the TM is the physical finding most specific for the presence of a
bacterial pathogen in middle ear fluid ( Fig. 58.2 A–D ). In children with acute
symptoms, impaired TM mobility with pneumatic otoscopy and the presence of
cloudy middle ear fluid are also strongly correlated with bacterial infection. A
TM that appears hemorrhagic or strongly red is associated with AOM, but lesser
degrees of redness are not useful diagnostically. Occasionally, examination of a
child with AOM will reveal bullae on the TM. The organisms responsible for
“bullous myringitis” are not significantly different from other cases of AOM and
treatment should be similar. Children with AOM and TM perforation may present
with purulent otorrhea that prevents adequate visualization of the TM. Otitis
externa can usually be excluded on clinical grounds, so a presumptive diagnosis
of AOM with perforation can be made.

Otitis media with effusion (OME) is the current term for a condition described
by fluid in the middle ear cavity without signs and symptoms of acute


inflammation. It may result from Eustachian tube dysfunction or represent the
aftermath of resolved AOM, but is not an acute bacterial infection.
Patients with ear pain from AOM should receive analgesic treatment because
antibiotics do not generally provide symptomatic improvement for at least 24
hours. Ibuprofen or acetaminophen are effective analgesic treatments of AOM.
Topical anesthetic–containing ear drops provide prompt, but short-lived pain
relief. Benzocaine-containing drops are no longer available in the United States
because their safety has not been adequately studied and benzocaine can cause
methemoglobinemia, especially in younger patients. These oil-based preparations
should not be administered if the TM has ruptured. Narcotic analgesia can be
used for very severe pain, but should rarely be necessary. Efforts toward
alternative approaches to pain management should be maximized first.


FIGURE 58.2 A: Normal tympanic membrane (TM). B: TM full/mild bulging (antibiotic
treatment not indicated). C: TM with moderate bulging. D: TM with severe bulging.

Antibiotic treatment of AOM has been controversial due to the high
spontaneous resolution rate of AOM in many older studies. Using a more
stringent diagnostic threshold for AOM, recent studies have documented a
modest but statistically significant benefit of antibiotics for AOM. Antibiotic
treatment is recommended for any child with AOM and severe symptoms,
defined as moderate or severe otalgia, otalgia for greater than 48 hours or
temperature >39°C (102.2°F). For children between 6 and 24 months of age,
observation without antibiotics is an option if AOM is unilateral and symptoms
are not severe. Observation is an option for patients >24 months of age with

AOM without severe symptoms even if the AOM is bilateral. In all cases for
which observation is the chosen option, the clinician must arrange for follow-up