Snapshot A 9-month-old male presents to your urgent care clinic for irritability and ear pain. One week prior to presentation, the patient had an upper respiratory infection, which has since improved. Over the last day, the mother has noticed that the child has been tugging at his right ear, refuses to lie down on it and has had a fever. The patient’s vital signs are stable. On physical exam you note that the right tympanic membrane is erythematous, bulging and minimally mobile with pneumatic otoscopy. Introduction Usually in children and resolves with age due to changes in anatomy and physiology with growth Often precipitated by a viral URI It is important to differentiate between acute otitis media and otitis media with effusion acute otitis media occurs more rapidly with signs and symptoms of inflammation otitis media with effusion has no signs or symptoms of acute inflammation, generally asymptomatic Pathyphysiology and Risk Factors Anatomic/Physiologic Eustachian tube is shorter, wider and horizontal in children when compared to adults cleft palate Infectious S. pneumonia H. influenzae Moraxella catarrhalis Respiratory syncytial virus (RSV) Other predisposing conditions include URI trisomy 21 (Down's Syndrome) cleft palate CF immune deficiencies 2nd hand smoke day care previous ear infections Presentation Symptoms ear tugging fever hearing loss irritability feeding difficulties vomiting Physical exam bulging or fullness of the tympanic membrane (TM) erythema of the TM possible perforation with otorrhea possibe absence of light reflex Evaluation and Diagnosis Pneumatic otoscopy for visualization of the TM and also important in assessing mobility of the TM Distinction between acute otitis media and otitis media with effusion (see above) Treatment Medical for acute otitis media amoxicillin is first-line which will provide coverage for S. pneumonia, usually 10 days amoxicillin-clavulanic acid will provide coverage for beta-lactamase producing H. influenza and M. catarrhalis cephalosporins can be used in those with penicillin allergy macrolides for patients with penicillin and cephalosporin allergies Surgical for acute otitis media myringotomy with tympanostomy tube insertion especially for recurrent cases Otitis media with effusion if the child does not have risk for speech and language development or other learning disabilities, observation may be appropriate Steroids, decongestants and antihistamines do not completely resolve effusion Prognosis, Prevention, and Complications Mastoiditis Sigmoid sinus thrombus Meningitis Subdural abscess Subdural empyema Brain abscess Lateral sinus thrombosis Hearing loss Balance problems Cholesteatoma