Acute otitis media — branching viva

Opening

Examiner: A 16-month-old is brought to you with two days of a cold, ear tugging and a fever. Pneumatic otoscopy shows a bulging, opaque, poorly mobile right tympanic membrane; the left is normal. How do you make the diagnosis and what is your first step? [1]

Candidate: This is acute otitis media of the right ear, confirmed by a bulging tympanic membrane that has lost its mobility on pneumatic otoscopy — the key finding, supported by the acute otalgia and fever and the preceding viral prodrome. My first step in every child with AOM is analgesia: paracetamol 15 mg/kg orally every four to six hours, or ibuprofen 5 to 10 mg/kg every six to eight hours, because the pain is often severe. The antibiotic decision is a separate step that depends on age, laterality and severity. [1] [2]

Branch 1 — the antibiotic decision

Examiner: So will you give an antibiotic? [1]

Candidate: I would apply the age-and-laterality matrix. He is 6 to 23 months with unilateral non-severe AOM — mild fever, still playing between bouts — and if the family is reliable I would offer watchful waiting with a safety-net rather than immediate antibiotics. The Cochrane evidence shows most children recover without antibiotics, with a modest average benefit concentrated in the youngest, the bilateral and those with otorrhoea. I would give a written safety-net to return at 48 to 72 hours if not improving, or at any time if worse. [1] [3]

Examiner (probe): Which children do get immediate antibiotics? [1]

Candidate: Any child under six months with AOM; children 6 to 23 months with bilateral AOM, whether severe or not, or with unilateral severe AOM; and any child two years or older with severe AOM. Severe means otalgia interfering with activity or a fever of 39 degrees Celsius or higher. [1]

Branch 2 — first-line antibiotic and failure

Examiner: Suppose he meets criteria for antibiotics and has no allergy. What do you give, and at what dose? [4]

Candidate: High-dose amoxicillin 90 mg/kg/day orally in two divided doses, up to a maximum of 4 g/day, chosen to overcome intermediate penicillin resistance in pneumococci. I would treat for ten days in a child under two years. [1]

Examiner (probe): He has AOM with purulent conjunctivitis. Does that change your choice? [4]

Candidate: Yes. AOM with purulent conjunctivitis is caused by beta-lactamase-producing non-typeable Haemophilus influenzae, which does not respond reliably to amoxicillin alone, so I would use amoxicillin-clavulanate 90 mg/kg/day of the amoxicillin component instead. It is also my choice if plain amoxicillin fails at 48 to 72 hours. For a true penicillin allergy I would use a cephalosporin such as cefdinir or, for anaphylaxis, a macrolide such as azithromycin. [4] [1]

Branch 3 — the complication

Examiner: A different child: fever, toxic, and a swollen red tender area behind the ear with the pinna pushed forwards. Your response? [5]

Candidate: That is acute mastoiditis until proven otherwise, the commonest suppurative complication of AOM. It is a medical and surgical emergency. I would assess and stabilise the child, obtain intravenous access and cultures, start intravenous antibiotics covering the otitis pathogens, arrange urgent CT of the temporal bone, and involve ENT early for possible cortical mastoidectomy or drainage. I would not manage this as uncomplicated AOM with oral antibiotics. [5] [1]

Examiner (probe): Would you investigate uncomplicated AOM routinely? [1]

Candidate: No. AOM is a clinical diagnosis and needs no routine blood tests or imaging; the otoscopic findings carry it. I reserve tympanometry for an uncertain view, tympanocentesis for treatment failure or immunocompromise, and imaging for suspected complications like this. [1]

Close

Examiner: Summarise your safe approach to acute otitis media in one line. [3]

Candidate: Diagnose on the bulge and the loss of mobility, never on redness alone; give analgesia to every child; split the antibiotic decision by the age-and-laterality matrix with high-dose amoxicillin first-line; reassess and safety-net at 48 to 72 hours; and treat the toxic child or any postauricular sign as acute mastoiditis with imaging, intravenous antibiotics and ENT. [1] [5]