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This chapter is limited to infections of the ears, nose, neck, and throat. Further information can be found in Chapter 69 “Upper Respiratory Emergencies-Stridor and Drooling,” as well as Chapter 151 “Ear, Nose Emergencies,” and Chapter 153 “Neck and Upper Airway Disorders.”

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Acute otitis media (AOM) accounts for 13% of all visits to emergency departments in the United States. AOM is an infection of the middle ear space that commonly affects young children because of relative immaturity of the upper respiratory tract, especially the eustachian tube. The most common pathogens in the post-pneumococcal vaccine era are Streptococcus pneumoniae (31%) and nontypeable Haemophilus influenzae (56%).

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Clinical Features

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Peak age is 6 to 36 months. Symptoms include fever, poor feeding, irritability, vomiting, ear pulling, and earache. Signs include bulging, pus behind the tympanic membrane (Fig. 68-1), an immobile tympanic membrane (TM), loss of visualization of bony landmarks within the middle ear, and bullae on the TM (bullous myringitis). Mastoiditis is the most common suppurative complication of AOM. The primary symptoms of mastoiditis include fever, protrusion of the auricle, and tenderness over the mastoid.

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Figure 68-1.
Graphic Jump Location

Acute otitis media in a 3-year-old child with an outward bulge of the tympanic membrane and an exudative process in the middle ear space. (Courtesy of Dr. Shelagh Cofer, Department of Otolaryngology, Mayo Clinic.)

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Diagnosis and Differential

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Making an accurate diagnosis is the most important first step. The definition of acute otitis media requires three equally important components: (a) acute onset (< 48 hours) of signs and symptoms, (b) middle ear effusion (see Fig. 68-1), and (c) signs and symptoms of middle ear inflammation. A red TM alone does not indicate the presence of an ear infection. Fever and prolonged crying can cause hyperemia of the TM alone. Pneumatic otoscopy can be a helpful diagnostic tool; however, a retracted drum for whatever reason will demonstrate decreased mobility. Other common causes of acute otalgia are a foreign body in the external ear canal or otitis externa.

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Emergency Department Care and Disposition

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  1. Treatment of pain is essential for all children diagnosed with AOM. Topical analgesics such as benzocaine-antipyrene are recommended for routine use, unless there is a known perforation of the TM. Acetaminophen 15 milligrams/kilogram or ibuprofen 10 milligrams/kilogram can be used.

  2. Consider the use of a wait-and-see prescription for the treatment of uncomplicated AOM. Parents are given a prescription and told to wait and see for 48 to 72 hours, and if the child is not better or becomes worse, to fill the prescription. Contraindications to the use of a wait-and-see prescription are: age < 6 months, an immunocompromised state, ill-appearance, recent use of antibiotics or the diagnosis of another bacterial infection. If any of these conditions are met, the child should be prescribed an immediate antibiotic.

  3. Amoxicillin 40-50 milligrams/kilogram/dose PO given twice daily (or 30 milligrams/kilogram/dose three times daily) times daily remains the first drug of choice for uncomplicated AOM.

  4. Second line antibiotics include amoxicillin/clavulanate 40–50 milligrams/ kilogram/dose given twice daily. Cefpodoxime 5 milligrams/kilogram/dose ...

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