Acute Otitis Media
You may be rolling your eyes right now at the thought of reading about AOM. Certainly it is not as exciting to think about as Hirschsprung’s Enterocolitis and we see it so often there certainly can’t be anything new to learn. Well, sometimes it is important to re-learn basics as well (at least for myself this is true). In addition, AOM is the #1 reason antibiotics are prescribed to children in the USA… so we need to know it well.
- The problem: clinical history is a poor predictor of AOM, visualization of the TM can be difficult, and redness doesn’t always equate with inflammation. Inaccurate diagnosis leads to inappropriate use of antibiotics and all the potential problems that entails.
- The most important aspect of AOM is making the diagnosis accurately (you need 3 elements)
- Acute Onset of Symptoms
- Signs of Middle Ear Effusion
- Buldging TM, poor mobility, otorrhea, or air-fluid level
- Signs of Middle Ear Inflammation
- TM erythema or otalgia (that interferes with nl activity)
- A trick or two to help your examination:
- Distract the child (Child Life and Bubbles often distract even me)
- Teach the guardian how to safely restrain the child
- Remove the cerumen!
- Wet a small cotton-tip applicator with an alcohol swab
- Irrigate or use colace when necessary
- Have patience!
- Acoustic Reflectometry – use sound waves to determine the presence of middle ear effusion
- Treat Appropriately
- Most important therapy = PAIN Medications!
- It’s an infection… so antibiotics are needed right? Well….
- Many (including the AAP) advocate for an observation without antibiotics for those pts 6months – 2 yrs with UNcertain diagnosis or for those >2yrs with non-severe illness (severe = severe otalgia or fever ≥ 39°C).
- Recent literature (Hoberman, NEJM 2011) states that children 6 months to 23 months diagnosed with an AOM do “better” (shorter duration of symptoms and less treatment failures – and more diarrhea and diaper rash) when treated with antibiotics.
- Again, what is important is accurately diagnosing the condition in the beginning.
- If the decision is made to observe without antibiotic therapy, the parents can be given a prescription for Abx with instructions to fill it if the child does not improve in 48 to 72 hours, or see the PMD in 2 days. Follow-up is very important if no antibiotics are given.
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