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Chapter 12. Ear, Nose, and Throat

  • Epidemiology: 33% of all pediatric office visits; by 3 yo, 80% have ≥ 1 AOM
  • Pathophysiology: URI or inflammation → Eustachian tube dysfunction or occlusion → effusion → infection
  • Etiologic agents: Respiratory viruses >> Haemophilus influenzae (Post PCV7 52%, Pre PCV7 15-30%) > Pneumococcus spp. (Post PCV7 34%, Pre PCV7 25-50%) > Moraxella spp. (Pre PCV7 3%–20%) > GABHS > other (Pediatrics 2004;113:1451)
  • Diagnosis
    • History: Fever (especially increasing fever curve), URI, ear pain or fullness, hearing loss, vomiting, ear drainage or diarrhea.
    • Physical exam: Bulging tympanic membrane (TM), purulent material, air-fluid level, ↓ or no movement of TM, otorrhea, ± redness, ± bullae.
    • Best predictors are position (ie, bulging), mobility of TM (↓ or no movement of TM), and color (PIDJ 1998;17(6):540). Consider tympanocentesis and bacterial culture for children with recurrent or chronic disease.
  • Treatment
    • Pain and fever control are the most important interventions.
    • Within 24 hours, 61% of patients have resolution of symptoms without antibiotics.
    • Antibiotics (see table below) often do not change the duration of illness of AOM.

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Age

Diagnosis of AOM is Certain

Diagnosis of AOM is Uncertain

<6 mo

Start antibiotic treatment

Start antibiotic treatment

6–24 mo

Start antibiotic treatment

Observe with follow-up assured if the patient's condition is non-severe (temperature <39°C [102.2°F] and mild otalgia);

Start antibiotics if the patient's condition is severe (moderate to severe otalgia and temperature >39°C)

≥24 mo

Observe with follow-up assured if the patient's condition is non-severe (temperature <39°C [102.2°F] and mild otalgia);

Start antibiotics if the patient's condition is severe (moderate to severe otalgia and temperature >39°C)

Observe with follow-up assured

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Temperature >39°C (102.2°F)

Initial antibiotic choice

Treatment failure at 48–72 h after initial management

No

Amoxicillin, 80–90 mg/kg/day

(If penicillin allergic: Non–type I: cefdinir, cefuroxime, or cefpodoxime; type I: azithromycin, clarithromycin)

Amoxicillin–clavulanate, 90 mg/kg/day of amoxicillin with 6.4 mg/kg/ day of clavulanate

(If penicillin allergic: Non–type I: ceftriaxone for 3 days; type I: clindamycin)

Yes

Amoxicillin–clavulanate, 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate

(If penicillin allergic, ceftriaxone for 3 days)

Ceftriaxone for 3 days

(If penicillin allergic, tympanocentesis, clindamycin)

  • Single high-dose azithromycin (30 mg/kg/dose) is equal to amoxicillin in efficacy (PIDJ 2005;24:153).
    • Add topical agents as well for AOM with perforation or if the patient has tympanostomy tubes (eg, Ciprofloxacin; Ofloxacin).
  • Surgical treatment: Consider ENT referral if the patient has >3 episodes in 6 mo or >4 episodes in 1 yr.
  • Complications: Labyrinthitis, mastoiditis, intracranial extension, conductive hearing loss.

  • Epidemiology: Highest incidence <2 yo; 80% of <10 yo have had one episode of ome
  • Pathophysiology: Eustachian tube dysfunction: Resolution of AOM → OME (45% at 1 mo after and 10% at 3 mo after AOM); GER; anatomic (children with cleft palate)
  • Etiologic agents: Viruses > H. influenzae > Moraxella spp., bottle feeding, feeding supine, daycare attendance, allergies, smoke exposure
  • Diagnosis
    • Often OME is subjectively asymptomatic → no intervention ...

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