QUESTION

6-year-old boy is brought in my his mother to the office for evaluation of a 3-day history of irritability, fever, and ear pain.  She also says that his older sister has had a cold the past week, but it doesn’t seem to be that bad.  He is up to date on his immunizations.  She also report she has had an intermittent, non-productive cough, but denies any decrease in eating/drinking, diarrhea, or vomiting.

Vital signs show a BP-117/72, HR-94, RR-16, O2-100%, and T-99.2.  Physical exam reveals:

• General – Non-toxic appearing, NAD, WN/WD
• Skin – no rash
• Eye – sclera white, conjunctiva clear
• Ear – (below)

• Throat – OP clear, no erythema or tonsillar swelling
• Neck – no LAD
• Heart – RRR without M/G/R
• Lung – CTA without adventitial sounds
• Abdomen – S/NT/ND
• PV – 2+ pulses throughout, BCR < 2s
• Neuro – No focal deficits

Mother is wanting an antibiotic because the holiday season is here and she can’t afford to have him sick.

1. What is your diagnosis?
2. What is your treatment?
3. What do you tell the mother?

Answer

1. Diagnosis
   1. Viral Otitis Media
      1. Based on the 2013 consensus guidelines from Pediatrics, the following findings suggests a viral etiology:
         1. Non-toxic appearance
         2. Non-bulging tympanic membrane
         3. > 48hr onset of symptoms
         4. Temperature < 39°C (102.2°F)
         5. No middle ear effusion
2. Treatment
   1. Given the patient’s age (6yo), there are 2 acceptable options:
      1. Observation
         1. This is the ideal patient for close observation as it is most likely viral, immunocompetant, no ottorhea, no severe symptoms, and non-toxic appearing.  Treatment should be directed towards pain control and recommendations should be given to the parents on how to treat:
            1. Ibuprofen – 10mg/kg TID
            2. Acetaminophen – 10mg/kg TID
            3. Topic antipyrine/benzocaine – no longer available
            4. Topical lidocaine – off label, but can be used
      2. Antibiotic Therapy
         1. If the patient fails to improve in 48-72hr, then antibiotics are warranted. Duration of therapy for children > 2yo is 5-7 days.

Case Resolution

After examination of the patient and discussion with the mother, you recommend a course of MICOS:

Masterful Inactivity with Catlike Observations

You explain that his symptoms are likely viral and self-limiting and the best thing for him now is to control his pain.  You give the dosing guidelines for ibuprofen and acetaminophen and offer a prescription of topical lidocaine.  You encourage the mother to call back to the clinic in 3 days time if he is not improving, at which time you will call in a prescription for antibiotics.

References

1. Lieberthal AS, Carroll AE, Chonmaitree T. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-99. [pubmed]
2. Bolt P, Barnett P, Babl FE, Sharwood LN. Topical lignocaine for pain relief in acute otitis media: results of a double-blind placebo-controlled randomised trial. Archives of Disease in Childhood. 2008;93(1):40-4.  [pubmed]