Acute otitis media — formative SAQs

SAQ 1 (10 marks)

A 14-month-old boy presents with two days of coryza and a fever, and has spent the night crying and tugging at his right ear. On examination he is alert, pink and playing between bouts of pain; his temperature is 38.4 °C. Pneumatic otoscopy of the right ear shows a bulging, opaque, dull red-yellow tympanic membrane that does not move when you puff air into the speculum. The left drum is normal. [1] [2]

1. State the diagnostic finding that confirms acute otitis media and explain why redness alone is insufficient. (3) [1]
2. Outline your management, including analgesia and the antibiotic decision, with doses. (4) [1] [3]
3. Describe your safety-net advice and follow-up plan. (3) [1]

Model answer — SAQ 1

(1) Diagnostic finding (3). The diagnosis is confirmed by a bulging tympanic membrane with reduced mobility on pneumatic otoscopy, indicating a middle-ear effusion under pressure — together with the acute otalgia and fever. A red drum alone is insufficient and is the commonest cause of over-diagnosis, because crying, fever and a struggling child redden a normal ear drum; the discriminating finding is the bulge and the loss of mobility, not the colour. [1] [2]

(2) Management (4). First, give analgesia to every child: paracetamol 15 mg/kg orally every four to six hours (maximum 60 mg/kg/day, up to 4 g/day), or ibuprofen 5 to 10 mg/kg every six to eight hours (maximum 30 mg/kg/day). For the antibiotic decision, this is a child 6 to 23 months with unilateral non-severe AOM (mild fever, not interfering with activity) and a reliable family, so I would offer watchful waiting with a safety-net rather than immediate antibiotics. If I were prescribing immediately — for example, if the parents preferred it or could not return — I would use amoxicillin 90 mg/kg/day orally in two divided doses (maximum 4 g/day) for ten days. I would explain that most children recover without antibiotics, with the average benefit modest. [1] [3]

(3) Safety-net and follow-up (3). Give a concrete, written safety-net: return at any time if the pain worsens or does not improve, if he becomes toxic, drowsy or pale, if there is swelling or redness behind the ear, persistent vomiting, or if the family is worried. Arrange a planned review at 48 to 72 hours if he is not improving, at which point I would start or change antibiotics and re-examine for a complication. If an effusion or hearing concern persists beyond three months, arrange a hearing assessment. [1]

SAQ 2 (10 marks)

A 2-year-old girl presents with five days of ear discharge, fever and increasing irritability. Today her parents report she is drowsy, the right ear is pushed forwards, and there is a swollen, red, tender area behind the right ear. Her temperature is 39.5 °C, and she looks toxic. [4]

1. What is the most likely diagnosis, and which complication of otitis media is this? (3) [4]
2. Outline your immediate management priorities. (4) [4]
3. Discuss the pitfalls to avoid and the features that distinguish this from uncomplicated acute otitis media. (3) [1]

Model answer — SAQ 2

(1) Diagnosis (3). The most likely diagnosis is acute mastoiditis, the commonest suppurative complication of acute otitis media, with probable subperiosteal abscess. The diagnostic features are the toxic, febrile child with postauricular pain, swelling, erythema and tenderness and an ear displaced forwards and downwards by the abscess, in the setting of a preceding otitis media with discharge. [4]

(2) Immediate priorities (4). This is a medical and surgical emergency. Assess airway, breathing and circulation; obtain intravenous access; take blood cultures and inflammatory markers; and start intravenous antibiotics covering the otitis media pathogens (pneumococcus, Haemophilus, occasionally staphylococcus and anaerobes — for example a third-generation cephalosporin, adjusted to local guidance). Arrange urgent CT of the temporal bone to define the mastoid collection and exclude intracranial extension, and involve ENT early for consideration of cortical mastoidectomy or drainage. Manage pain and fever, and admit for ongoing care. [4]

(3) Pitfalls and distinguishing features (3). The key pitfalls are treating this as uncomplicated AOM with oral antibiotics and outpatient review, which delays definitive care; failing to recognise that the displaced pinna and postauricular swelling are not normal AOM; and not imaging or involving ENT early enough. This differs from uncomplicated AOM by the toxicity, the high fever, the postauricular signs and pinna displacement, the drowsiness (raising concern for intracranial extension), and the duration of discharge. The safe approach is early recognition, imaging, intravenous antibiotics and surgical assessment. [1] [4]