Sunday, August 9, 2009

Not Blowing Hot Air: Ear Infections

Know that acute otitis media in the first six weeks after birth requires careful evaluation and follow-up
Know that pneumatic otoscopy is the preferred generally available method of diagnosing middle ear effusion because dimished tympanic membrane mobility usually accompanies middle ear effusion
Know the clinical manifestations of acute otitis media:fever may or may not be present, otalgia, nonspecific symptoms (eg, irritability)

When I look into a child's ears to determine whether or not she has an infection of the middle ear, I'm supposed to use my instrument to blow a puff of air onto the eardrum. If it flexes normally, all is well; otherwise a lack of compliance suggests fluid there: but is it infected or not?.

The strict criteria for an ear infection as opposed to just having fluid in the middle ear includes three things 1) acute onset 2) an exam consistent with having middle ear fluid and 3) signs of inflammation there. The onset is usually pretty easy, but fluid that is not infected can accumulate rapidly as well, and uninfected fluid can hurt. Signs of inflammation are rampant, being either pain or redness: most children come in for ear pain, and one good cry is enough to make the eardrum as red as the child’s face. The exam for a middle ear effusion should be fairly easy, but with a frantic child in pain, it is often technically difficult. Wax gets in the way, the child moves, and curiously enough, our clinic doesn’t have any of the insufflation bulbs required to check ear drum compliance. When pus comes draining out of the ear (a sign of middle ear fluid), I sometimes heave a sigh of relief and get ready to write for some medicine.

I really like the AAP guideline’s little chart for diagnosing an ear infection, so I’ll reproduce it here:

A diagnosis of AOM requires 1) a history of acute onset of signs and symptoms, 2) the presence of MEE, and 3) signs and symptoms of middle-ear inflammation. Elements of the definition of AOM are all of the following:
1. Recent, usually abrupt, onset of signs and symptoms of middle-ear inflammation and MEE
2. The presence of MEE that is indicated by any of the following:
a. Bulging of the tympanic membrane
b. Limited or absent mobility of the tympanic membrane
c. Air-fluid level behind the tympanic membrane d. Otorrhea
3. Signs or symptoms of middle-ear inflammation as indicated by either
a. Distinct erythema of the tympanic membrane or
b. Distinct otalgia (discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep)

Abbreviations: TM, AOM, OME, MEE

Reference: American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics (2004) vol. 113 (5) pp. 1451-65.

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