Case 14

18-MONTH-OLD WITH CONGESTION - REBECCA

Author: W. Scott Jones, M.D., and Jeffrey Longacre, M.D., Uniformed Services
University of Health Sciences
Learning Objectives
Identify age-appropriate approaches to the acutely ill toddler. 1.
Identify appropriate developmental milestones and screening tools for the
assessment of a toddler.
2.
Describe findings associated with a normal tympanic membrane, acute otitis
media (AOM), and otitis media with effusion (OME) using proper techniques
and skills.
3.
List management options for uncomplicated AOM. 4.
Recognize the indications and various methods for performing an
age-appropriate hearing screen.
5.
List management options for OME. 6.
Summary of clinical scenario: 18-month-old Rebecca has had several days of
nasal congestion, cough, decreased eating, and ear-tugging. Results of the
physical exam include a red, nonmobile tympanic membrane. Rebecca is
diagnosed with acute otitis media, which is treated with high-dose amoxicillin.
When Rebecca returns four months later, she has bilateral, bulging, yellow, and
poorly mobile tympanic membranes, leading to a diagnosis of otitis media with
effusion.
Key Findings from
History
Fever
Tugging at ears
Congestion/rhinorrhea
Cough
Waking at night
Questionable language delay
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Key Findings from
Physical Exam
At first visit: TMs are bilaterally
bulging, opaque, yellow/red, and poorly
mobile
Four months later: Bilateral, amber,
nonmobile, retracted, opaque tympanic
membranes
Differential
Diagnosis
Upper respiratory infection
Sinusitis
Acute otitis media
Pneumonia
Allergies
Key Findings from
Testing
Hearing screen: Mild hearing loss
Final Diagnosis
First visit:
Acute otitis media
Second visit:
Otitis media with effusion
Mild speech delay
Case highlights: Students learn the best way to approach examining a toddler
and several positions for attaining good views of the middle ear. Videos and stills
teach various infected states of the middle ear. The case teaches the bacterial
organisms that most frequently cause acute otitis media (AOM), risk factors for
children developing AOM, and antibiotic choices for treating it. When the patient
returns four months later, the students learn how to diagnose and manage otitis
media with effusion (OME). Also explored are the Denver II developmental screen
and tests to assess hearing loss. Multimedia features include vivid videos showing
normal and infected middle ears during insufflation, photographs of diseased
middle ears and one with a tube in place, and an example of a Denver II
assessment.
Key Teaching Points
Knowledge
Acute otitis media (AOM): Infection of fluid in middle ear space.
Etiology
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Bacterial:
Streptococcus pneumoniae (2550%)
Haemophilus influenzae, nontypeable (1552%)
Moraxella catarrhalis (320%)
Streptococcus pyogenes (< 5%)
Viral (viruses alter mucosal liningincreasing bacterial colonization of
nasopharynxor may act as sole pathogen):
Respiratory syncytial virus (RSV)
Influenza
Rhinovirus
Risk factors
Child care attendance
Tobacco exposure
Respiratory allergies
Bottle propping
Pacifier use
Formula-feeding
Family history of AOM
Male
Lower socioeconomic status
Onset of otitis in first year of life
Conditions affecting craniofacial structure (cleft palate, Down syndrome)
Genetic predisposition (Native American)
Signs and symptoms
Prior or current upper respiratory tract infection
Fever
Fussiness
Sleeplessness
Otalgia (rubbing or tugging at ears)
Decreased hearing
Vomiting
Poor appetite
Otitis media with effusion (OME):
Fluid in the middle ear space without signs and symptoms of acute
inflammation
Otitis externa (swimmers ear):
Edematous external auditory canal
Pain with traction on the ear lobe
Occasionally follows perforation of the TM in AOM
Skills:
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Physical exam: Start with least invasive or potentially irritating aspects of the
examination first:
Observations of the childs behavior, degree of alertness, and interactions
with her parents
Examine heart, lungs, and abdomen
Briefly look at the eyes for conjunctiva erythema or discharge (in case child
cries with subsequent evaluation)
Examine ears and oral cavity last
Pneumatic otoscopy: Enables assessment of the tympanic membrane
(TM)including its mobilitythrough an otoscope using an insufflation bulb.
Examination of patients ears: Parent participation should be attempted first.
Ears may be viewed most easily if child is placed:
On parents lap
On parents chest
On the exam table
The pinna should be pulled up and back to help see past anterior bend in the
external auditory canal.
Place hand close to the head of the otoscope to guard against sudden motions.
What to look for: COMPT is a useful mnemonic to remember how to describe ear
exam findings:
C=Color (red, amber, blue, white, gray or yellow)
O=Other (bubbles, scarring or perforation)
M=Mobility (absent, reduced, normal or hypermobile)
P=Position (normal, retracted or bulging)
T=Translucency (opaque or translucent)
A normal TM is translucent with neutral or retracted position and normal mobility.
Denver developmental assessment, 2nd edition:
Standardized developmental screening tool for children birth to 6 years of
age.
Social, fine-motor, language, and gross-motor developmental domains are
assessed for potential delays.
Subsequent referral for more definitive developmental testing should follow
if screening reveals a concern.
Differential diagnosis
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Upper respiratory tract infection (URI): Symptoms vary depending on
viral agent but may include throat irritation, sneezing, nasal congestion,
cough, and irritability.

1.
Acute otitis media (AOM): Typically develops 35 days after onset of
URI. Symptoms include fever and otalgia (tugging on ears in a younger
child).

2.
Otitis media with effusion (OME): Fluid (effusion) in middle ear without
signs or symptoms of infection. May occur alone, secondary to URI or
consequence of AOM.

3.
Sinusitis: Caused by superinfection of pathogenic bacteria following viral
URI. Persistent URI symptoms (> 10 days) with day and night cough are
typical in pediatric cases.

4.
Pneumonia: Bacterial pneumonia (much less common than viral) signaled
by abrupt onset high fever, productive cough, and chest pain. May see
dyspnea and tachypnea. Viral pneumonias often present with moderate
fever, nonproductive cough.

5.
Allergic rhinitis: May be seasonal or perennial depending on type of
environmental allergen. Not likely if fever also present.
6.
Less likely diagnoses
Gastroenteritis: Unlikely in absence of significant vomiting or diarrhea.
Urinary tract infection (UTI): UTI is an important cause of fever in girls
this age, especially for those with no apparent source of fever by history or
exam. In the absence of a definitive source of fever (e.g., pneumonia or
otitis media), or in the setting of persistent fever, UTI should be
reconsidered.
Studies
Audiology tests:
Tympanogram: Objective method for evaluating TM mobility.
Conventional audiometry: Behavioral test measuring auditory thresholds in
response to speech and frequency-specific stimuli presented through earphones.
Used for patients 4 years old and older.
Visual reinforcement audiometry (VRA): Behavioral test measuring response
of the child to speech and frequency-specific stimuli presented through speakers
in sound-proof room.
Audiologic evaluation for kids aged 6 to 30 months, because conventional
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< 6
months
6 months2 years > 2 years
Certain
diagnosis
Treat with
antibiotic
Treat with antibiotic
Antibiotics if
severe* illness
Observation***if
nonsevere** illness
Uncertain
diagnosis
Treat with
antibiotic
Antibiotics if
severe* illness
Observation*** if
nonsevere**
illness
Observation***
audiometry is not appropriate at very young ages.
Otoacoustic emissions (OAE): Physiologic test measuring cochlear function in
response to presentation of a stimulus. Primarily used in newborn assessments.
Management
Cough and congestion in an infant or young child:
The U.S. Food and Drug Administration published an advisory in January 2008
that over-the-counter cough and cold products not be used for infants and
children under 2 years of age due to lack of demonstrated benefit and prevalence
of reported adverse events, including fatal overdoses.
Acute otitis media (AOM):
Treatment recommendations (Note that AOM resolves spontaneously 5080%
of the time):
*Severe
illness is
defined as
moderate
to severe
ear pain or
fever > 39
degrees C.
**Nonsevere illness is defined as mild ear pain and temperature < 39 degrees C
in previous 24 hours.
***The observation option should be offered only when good follow-up can be
assured and antibiotics can be started should the childs condition worsen or not
improve in 48 to 72 hours.
Reference: American Academy of Pediatrics and American Academy of Family
Physicians Clinical Practice Guideline. Diagnosis and Management of Acute Otitis
Media. Pediatrics 2004;113:1451-1465.
Complications: Mastoiditis, meningitis, or intracranial spread
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Antibiotics:
Amoxicillin:
Preferred first-line therapy for AOM
Use high-dose regimen, 80-90 mg/kg/day
Inexpensive
Tastes good
Relatively good safety profile
Fairly narrow in antibacterial activity spectrum
Amoxicillin/clavulanate (high-dose):
Recommended by American Academy of Pediatrics and American Academy
of Family Physicians for children with higher fevers (> 39 degrees C) or
moderate to severe otalgia.
Greater efficacy in treating nontypeable Hemophilus influenza, which is
increasing in prevalence.
Otitis media with effusion (OME):
Cognitive effects of long-term OME are controversial.
If mild hearing loss but no language concern, "watchful waiting" for another
36 months with follow-up hearing test is an option.
If persistent OME, especially with associated language delay, referral for
tympanostomy tube placement would be optimal.
No strong evidence that early placement of tympanostomy tubes in
otherwise healthy children with persistent OME improves developmental
outcomes at 3, 4, 6 or 911 years of age.
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