Explain acute otitis media and a safety-net plan to a parent — OSCE

Candidate instructions

You are the paediatric registrar. A 14-month-old boy has non-severe unilateral acute otitis media confirmed on otoscopy. He is well, feeding, alert, and his parents are reliable. You have decided on a watchful-waiting (safety-net) approach with analgesia and no immediate antibiotic. His mother has ten minutes with you before going home. She wants to understand, in plain language: (1) what an ear infection is; (2) why he is not getting antibiotics when her older child always did; (3) what to give for his pain; and (4) exactly what to watch for and when to come back. Explain with empathy, check understanding, and agree a clear plan. [1]

Encounter

Mother: "What actually is an ear infection? He kept grabbing his ear all night." [2]

Registrar: "It is really distressing to watch, I understand. An ear infection — acute otitis media — is a build-up of infected fluid behind his eardrum, usually after a cold. The tube that normally drains the middle ear to the back of the nose gets blocked, fluid collects, and the germs that live in the nose multiply in it. That fluid under pressure is what pushes the eardrum out and causes the earache and the fever. It is extremely common at his age, and the good news is that most children get better on their own over a couple of days." [2]

Mother: "But my older one always got antibiotics for his ear infections. Why isn't he?" [3]

Registrar: "That is a fair question, and practice has changed for good reason. Careful studies show that most ear infections settle on their own within two to three days whether or not we give antibiotics, and antibiotics only make a small difference on average — while they can cause diarrhoea, rash and an upset stomach. So for a child like yours — over six months, with one ear affected and not too unwell, and with you able to bring him back — the safest and best plan is to watch and wait for 48 to 72 hours, treat his pain well, and start antibiotics only if he is not improving or gets worse. I will not leave you without a plan — you will have a clear safety-net." [3] [1]

Mother: "So what should I give him for the pain?" [4]

Registrar: "Regular pain medicine is the most important thing. You can give paracetamol — about 100 mg for his weight, every four to six hours as needed, no more than four times in 24 hours — or ibuprofen, again by his weight. Either works; you can use whichever he tolerates, and some parents alternate them. The pain often flares at night, so giving a dose before bed helps. Keep him drinking, and prop him up a little if lying flat hurts. I will write the exact doses for his weight." [4]

Mother: "When do I need to bring him back?" [1]

Registrar: "Here is the plan, and I will write it down. First, bring him back at 48 to 72 hours — that is, in two to three days — if his earache or fever has not improved, and we will start antibiotics then. But come back straight away, at any time, if he becomes more unwell or drowsy, if he is not drinking, if his breathing is fast, or — very importantly — if you notice any swelling, redness or tenderness behind his ear, or his ear looks pushed forward. Those can be signs the infection has spread, and we would want to see him urgently. And of course come back any time you are simply worried. Shall I check I have explained that clearly — can you tell me the two main reasons to bring him straight back?" [1]

Mother: "Yes. If he is not better in two to three days, and straight away if he gets more unwell or has swelling behind the ear." [1]

Registrar: "Exactly. I will give you a written sheet with those warning signs and our number. One more thing — his hearing may be a little muffled for a few weeks while the fluid clears, and that is normal; we only check his hearing if it has not settled in about three months." [2]

Examiner debrief

A strong candidate explains acute otitis media in plain language (fluid behind the drum after a blocked tube), justifies the watchful-waiting approach with the evidence rather than dismissing the mother's expectation, gives correct weight-based analgesia advice, and delivers a concrete, specific safety-net — distinguishing the 48 to 72 hour routine review from the immediate "return now" red flags, especially the postauricular signs of mastoiditis. They use teach-back to confirm understanding and provide written information. Pitfalls include reflexively prescribing antibiotics to satisfy the parent, vague safety-netting ("come back if worse"), failing to mention the mastoiditis red flag, and not addressing the parent's comparison with an older sibling. [1] [3]