In this lecture, we will review otitis
media, mastoiditis and otitis externa,
basically all problems with pediatric ears.
Let’s start with otitis media.
Here’s a picture of an ear.
As you can see, there’s the
external ear and the ear canal.
That’s infected in otitis externa.
Behind the tympanic membrane is this red
chamber here, which is the middle ear.
That’s where otitis media occurs
and that area is drained by a
tube that goes down to the nose.
When that tube is
closed off or inflamed,
you can create an otitis media
as bacteria grow in that chamber
and the pressure builds up and
it becomes very uncomfortable.
That’s otitis media.
So, acute otitis media is generally
an acute bacterial infection.
This is to be distinguished
with otitis media with effusion
which is usually non-infectious.
This may be something like allergy
or a reaction to secondhand smoke
causing a poor drainage of that
tube and buildup of pressure
but not with primarily
So let’s talk about infectious
otitis media first.
Ninety percent of children will
get it before the age two.
The peak age is between 6
months and 18 months of age
and it’s usually associated
with a viral URI.
Basically, you have a viral infection
and that closes off that drainage tube
and then bacteria can take over and start
growing in that middle ear chamber.
The classic pathogens are Strep pneumo,
nontypeable H. flu and
Strep pneumo, nontypeable H flu
and Moraxella catarrhalis,
common question on tests.
So are there some risk factors?
Sure, especially risk factors for
upper respiratory infections
like daycare exposure or being alive during
the winter months is plenty risk alone.
But there are other specific
otitis media risk factors,
so that when they get that cold
it turns into an ear infection.
One is secondhand smoke exposure.
Another one is an infant
that does not breastfeed.
Breastfed infants are far less
likely to develop otitis media
than non-breastfed infants.
Infants with a cleft palate
or other craniofacial anomaly
may have an abnormality of the
drainage of that Eustachian tube.
Patients with Down syndrome, for example,
can have large tonsils and adenoids
which can interfere with drainage and they
are at increased risk for otitis media.
Also, if a family didn’t get
a vaccine for strep pneumo,
they are at increased
risk for otitis media.
So how does otitis media present?
Generally with fever and fussiness, ear
pain and sometimes grabbing at ears.
Although be careful, there is age at
which kids sort of discover their ear
and that doesn’t necessarily
mean there is something wrong.
Certainly, if there is otorrhea
or pus coming out of the ear,
that’s a clear sign that not only there has
been an infection but it is perforated.
The good news for the patient
is once it perforates,
it’s far less painful, because
that pressure has been relieved.
So let’s talk about otoscopy.
This is when you look
at a patient’s ear.
Here’s a normal ear.
You can see some landmarks like the bony
structures, the malleus and the incus.
You can’t see the stapes, it’s farther end.
And you can see a normal light
reflex there, it looks pretty good.
Here’s the caveat though and I’m just
going to bring this up and say it,
is that you have probably as a student
seen lots of people look in the ears
and say, “Oh, looks red to me," "Looks
infected" or "Looks normal to me”
and they didn’t insufflate.
that’s when use that bulb to
move the eardrum back and forth,
you’re actually doing a far worse exam
and I don’t care how
good you are at ears.
I don’t care if you’re the
best ear doctor on the planet.
If you’re not doing pneumatoscopy,
you’re having a hard time distinguishing
those ears that are middle ground.
Certainly, we have all looked in
there and seen a horrible ear
and didn’t need to
But on those borderline
cases, if that ear is moving,
that means that Eustachian tube is patent
because the pressure can be relieved
by blowing down that
So, a mobile ear is far less concerning
and we can probably save ourselves a
lot of infected eardrum treatments
if we simply check with
because if that ear is moving, you
should be much less concerned.
So movement is the most
important part of the ear exam
and without that bulb, you
really aren’t checking for it.
So here is an example of an infected
ear, you can see it’s bulging.
You can see, you no longer can clearly
see the bony landmarks of that ear.
This is a bad ear infection.
Here is a serous otitis.
It’s bulging a little bit,
but it’s not too bad.
You can see that there
is some bulge there.
So how do we manage otitis media?
Well, we have made the diagnosis.
The patient has a purulent
appearing TM and it’s not moving.
Well, if the child is
over six months of age,
the first step may well
be watchful waiting.
Not every otitis media
This is especially true
in non-severe infections
and what you might do is watch
off antibiotics for two to three days
and then treat if
it doesn’t improve.
Some practitioners like to give them
on a script to say wait two days.
If it’s still bothering them, then fill it.
There is a lot of
variability in practice.
One thing that's clear though is we should
treat for fever and pain with ibuprofen
and that’s indicated.
So if we decide then to
treat, it’s a severe case,
it’s a kid under six months of age
or it’s been two days and
it’s not getting better,
then our first line
antibiotic is amoxicillin
high dose which is 80-90
mg per kilo per day
divided twice a day.
Why high dose?
Well, there is one bacteria in particular
that develops resistant to amoxicillin
by altering its penicillin
that’s Streptococcus pneumoniae.
If you have a patient with
Strep pneumo which is
the number one bacterial
cause of otitis media,
you’re going to need the higher
dose to encourage the penicillins
to be more in the bound form with
the penicillin-binding protein.
In other words, by raising those, you sort
of the force that equation to the right.
You create more binding.
Okay, if the high dose amox fails,
then we may say, maybe there’s
a resistant gram negative.
Strep pneumo is almost ubiquitously
sensitive to high dose amox.
So then, you would go to Augmentin
because you’re adding a beta lactamase
that will be treating
the resistant forms of
H. flu non-typeable or
Alternatively, you may
also use ceftriaxone,
but we’re trying to limit the amount
of ceftriaxone we use in this world
since resistance to third generation
cephalosporin is going to be a problem
of your generation even
more than it is of mine.
Lastly, if it’s still
you might consider ENT referral
for a myringotomy and a culture.
Myringotomy will immediately
relieve the pain
and the culture will give you
a sense of why exactly this
patient isn’t responding to
the standard antibiotics.
We also want to refer to ENT if there’s
a problem that is chronic in nature
or if a patient is getting
recurrent otitis media.
They may be able to put
in tympanostomy tubes.
Here you can see an ear where
they have inserted a tube
into the tympanic membrane to
allow for continuous drainage.
This is great.
Now this patient doesn’t need
their Eustachian tube to drain.
There is one coming straight
out of the eardrum.
This prevents buildup of pressure
and prevents that backlog of bacteria
growing behind that tympanic membrane.
It may improve hearing, but it does
not improve long-term speech problem
and this is not recommended for hearing
issues and speaking issues alone.
It’s really for recurrent
or chronic otitis.