Family Medicine · Year 3 · from Family Medicine

Case 2: Acute Otitis Media

Patient Demographics

  • Age: 2 years old
  • Sex: Female
  • Accompanied by: Mother

Chief Complaint

Mother: "She's been crying and pulling at her right ear since last night. She feels warm."

History of Present Illness

Sophia is a 2-year-old girl brought in by her mother with ear pain and fever. She developed runny nose and cough 4 days ago, which the mother was managing with supportive care. Last night, she became more irritable, refused to eat dinner, and started pulling at her right ear. She had a temperature of 102.1F (38.9C) at home. She slept poorly, waking frequently and crying. Today she is still fussy and febrile. She has had no vomiting or diarrhea. No rash. She has been drinking fluids.

Past Medical History

  • One prior episode of acute otitis media at 15 months, treated with amoxicillin
  • No chronic medical conditions
  • Immunizations up to date (including PCV13)

Social History

  • Attends daycare 5 days per week
  • No smokers in household
  • No bottle propping

Physical Examination

  • Vital Signs: Temp 101.8F (38.8C), HR 120, RR 24, SpO2 98%
  • General: Fussy toddler, consolable in mother's arms
  • HEENT:
  • Right TM: Bulging, erythematous, opacified, decreased mobility on pneumatic otoscopy, no visible perforation
  • Left TM: Mildly erythematous (consistent with crying), mobile, landmarks visible
  • Nasal mucosa edematous with clear discharge
  • Pharynx: Mild erythema, no exudates
  • Neck: No lymphadenopathy
  • Lungs: Clear to auscultation bilaterally
  • Cardiovascular: Tachycardic but regular, no murmur

Clinical Image

Image: Otoscopic view comparing normal tympanic membrane (pearly gray, translucent, mobile, landmarks visible) with acute otitis media (bulging, erythematous, opacified, reduced mobility).

Image Source: Wikimedia Commons Attribution: B. Welleschik, CC BY-SA 3.0 URL: https://commons.wikimedia.org/wiki/File:Otitis_media_acute.jpg

Assessment and Diagnosis

  1. Acute otitis media, right ear - meets diagnostic criteria (acute onset, middle ear effusion with bulging TM, signs of middle ear inflammation)
  2. Upper respiratory infection - viral, typical prodrome

Diagnostic Criteria for AOM (all three required)

  1. Acute onset of symptoms - YES (developed overnight)
  2. Middle ear effusion - YES (bulging TM, decreased mobility)
  3. Signs/symptoms of middle ear inflammation - YES (erythema, otalgia)

Management Plan

Antibiotic Therapy:

  • Amoxicillin 90 mg/kg/day divided BID for 10 days
  • High-dose amoxicillin is first-line
  • Patient weighs 12 kg: 90 x 12 = 1080 mg/day = 540 mg BID
  • Prescribe amoxicillin 400 mg/5mL suspension: 6.75 mL (approx 7 mL) twice daily

Why NOT observation option:

  • Age under 2 years with unilateral AOM typically warrants antibiotics
  • Observation option appropriate for: children 6-23 months with mild, unilateral non-severe AOM OR children 24 months+ with unilateral mild AOM
  • This patient has moderate symptoms (high fever, significant irritability)

Symptomatic Treatment:

  • Ibuprofen 10 mg/kg every 6-8 hours PRN for pain and fever
  • Warm compress to affected ear for comfort

Parent Education:

  • Complete entire course of antibiotics even if symptoms improve
  • Symptoms should begin improving within 48-72 hours
  • Return if: fever persists >72 hours, symptoms worsen, new symptoms develop
  • Do not put anything in the ear canal

Follow-Up

  • Recheck not routinely needed if symptoms resolve
  • Return if not improving in 48-72 hours
  • Consider audiology referral if recurrent AOM (3+ episodes in 6 months or 4+ in 12 months)

Teaching Points

  1. Diagnosis of AOM requires three criteria: acute onset, middle ear effusion (bulging TM, decreased mobility), and inflammation/pain
  1. High-dose amoxicillin (90 mg/kg/day) is first-line to overcome relative resistance of Streptococcus pneumoniae
  1. Treatment duration:
  • Age <2 years or severe symptoms: 10 days
  • Age 2-5 years with mild-moderate: 7 days
  • Age 6+ years with mild-moderate: 5-7 days
  1. Observation option (48-72 hours of watchful waiting) is appropriate for:
  • Children 6-23 months with unilateral, mild, non-severe AOM
  • Children 24 months+ with unilateral or bilateral mild AOM
  • Requires reliable follow-up and ability to start antibiotics if worsening
  1. Switch to amoxicillin-clavulanate if:
  • Treatment failure after 48-72 hours
  • AOM within 30 days of previous antibiotic course
  • Concurrent purulent conjunctivitis (suggests H. influenzae)

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