A 2 year old boy is brought into a general practice clinic by his mother with two days of fever

and reduced oral intake. Mother reports rhinorrhoea and coughing for 2-3 days and has
noticed that the child has been pulling at his left ear. The highest recorded temperature was
38.3 degrees Celsius (tympanic).

Questions:

1. What are the possible diagnoses? What is the likelihood of a serious cause of fever in
this child?

 My impression is that this patient is suffering from acute otitis media (AOM) most
likely secondary to a viral URTI.
 However, I would want to consider other differentials including:
o Otitis media with effusion (glue ear) - middle ear effusion without signs of
inflammation, predominant symptom is hearing loss.
o Otitis externa.
o Acute mastoiditis.
o Cholesteatoma - congenital or aquired (more common due to recurrent AOM
or chronic suppurative OM).
o Trauma to the ear.
o Foreign bodies in the ear canal.
o Referred pain from teeth, sinuses, throat, or jaw.
 My overall aims in this case are to:
o Assuming the patient is haemodynamically stable, perform a targeted H+E,
more pertinently an otoscopic exam to confirm the diagnosis of AOM and
exclude complications.
o Provide appropriate management with analgesia and antibiotics if indicated.

2. How would you make a decision on whether the child can be safely cared for at
home or needs to be referred to an Emergency Department?

- Most cases of AOM in children resolve spontaneously and antibiotics are not
recommended
- Bilateral
- associated with perforation of the tympanic membrane
- known immune deficiencies
- pyrexia greater than 39o C
- Facial palsy
- Mastoiditis
- Severe headache
- Changes in sensorium
- Neurological deficits
- Meningitic signs
- Nystagmus
- Vertigo
- Affecting indigenous children including Aboriginal, Torres Strait islanders, Maoris and
those from other Pacific islands, who are more susceptible to recurrent AOM and
complications
- In patients who have a cochlear implant
- Affecting only hearing ear

3. How can you tell the difference between the important causes of otalgia in this
patient?
4. If the diagnosis is acute otitis media, how would you treat the patient? How would
the family’s social situation change this?
 Most children can be managed at home, consider admission if:
o Systemically unwell.
o Suspected intracranial extension of infection or acute mastoiditis.
o Neonates.
 Supportive management:
o Parental reassurance and education - provide handout:
 Encourage breast feeding, feed child upright if bottle feeding
 Avoid passive smoking/dummy use
 Ensure vaccinations up to date – especially strep pneumoniae
 Teach the child to blow their nose.
o Simple analgesia - e.g. panadol and neurofen.
 Consider 1-2 drops of Topical 2% lignocaine for severe ear pain (only if
tympanic membrane INTACT)
o Fluids - frequent small volume oral clear fluids.
o Warm saline nose drops:
 Helps relieve congestion and can help thin mucous and assist with feeding
for young children (obligate nose breathers).
o Safety net.
o NB: Steroids, antihistamines, decongestants etc. have no role in the management of
AOM.
 Definitive management:
o Antibiotic therapy - most cases of AOM in children resolve spontaneously and
antibiotics are not recommended:
 Consider antibiotics in patients with red flags:
 Symptoms not improving on supportive therapy for 48 hours.
 <6 months old.
 Immunocompromised.
 ATSI.
 Cochlear implant.
 Only hearing ear.
 Regimen - amoxycillin 30mg/kg/dose BD for 5 days.
 Review at 48 hours and consider switching to augmentin for 5 days.
 Social situations
o Access to medication –
o Compliance
o Health literacy