Virtual Pediatric Patients

Case 1 - A Cranky Child

Donna M. D'Alessandro M.D., Tamra E. Takle M2
Peer Review Status: Internally Peer Reviewed

The Problem / Clinical Presentation
"Last night when I was getting Damon ready for bed he didn't want to quiet down. He usually cries or yells for a while when I try to put him down for a nap or at night, and we've been working on getting him to quiet himself down but this was way more than usual. He would quiet down a little when I went in to see him and he seemed fine, but I did notice he was pulling at his ears, especially the right one. I finally just shut the door and went to a different part of the house, but he still screamed for probably close to an hour until I guess he wore himself out and went to sleep. This morning he was happier but still pulling at his ears, and I couldn't stand another night like last night so I brought him in to the Pediatrics Clinic."

Clinical Physical Exam
Damon is a smiling 9-month-old white male who waved his arms vigorously, making happy baby noises. He was an active and alert boy. His temperature was 37.9 C and his other vital signs were normal. His right ear exam showed the tympanic membrane to be erythematous with fluid behind the membrane and poor movement. His left tympanic membrane revealed normal landmarks but had slightly decreased movement. His nose exam showed minor mild erythema with clear to yellow nasal discharge. The rest of his physical examination was normal.

Clinical Differential Diagnosis
The differential diagnosis for a 9 month old with fussiness, fever and pulling of his ear would be:

• Otitis media
• Otitis externa
• Barotitis
• Pharyngitis

Clinical Labs
No clinical labs were done.

Laboratory Differential Diagnosis
Not applicable

Imaging Findings
No imaging studies were done.

Imaging Differential Diagnosis
Not applicable

Operative Intervention
No operative intervention was done.

Pathological Findings
Not applicable

Pathological Diagnosis
Not applicable

Treatment Course, Prognosis and Follow-up
Damon was treated with a 10-day course of oral Bactrim (trimethoprim/sulfa) which he took without problems and had resolution of his symptoms by day 3. At a 2-1/2 week follow-up visit, Damon's ear examination had returned to normal.

"This is actually the third ear infection Damon's had. His older brother's also has had a lot of them that sometimes we've had to use stronger medicine on."

The Approach to the Child With Ear Pain.

Ear pain or otalgia is one of the most common problems in childhood. For parents and many health care providers ear pain equals otitis media, but there can be other causes and providers must always perform a careful history and physical examination.

Differential Diagnosis
The differential diagnosis is shown below with otitis media being the most common cause.

• Otitis media
• Otitis externa
• Barotitis
• Impacted cerumen
• Skin abnormalities - herpes, atopic dermatitis, cellulitis, furuncle
• Foreign body
• Mastoiditis
• Referred pain - dental problems, pharynx, cervical spine
• Trauma to pinna

History and Physical
A complete history should be taken from the patient and/or family. Otitis media in small children can present with a simple history of fussiness with or without fever. Onset of pain, associated fever, sore throat, rash, rhinorrhea, and swelling of the head or neck should be discussed. The location and intensity of the pain can be difficult to discern in young children. Pulling of the ears is a common complaint heard from parents but this does not correlate with disease. Obvious causes such as trauma or foreign body insertion should also be discussed. A history of tinnitus or vertigo often can be obtained from older children.

The head and neck examination is the area of interest. The head and neck should be examined for lymphadenopathy and skin changes. The nose should be examined for rhinorrhea, and pharynx for erythema, exudates and dental abnormalities The external examination of the ear should look for pinna position and otorrhea. The tympanic membranes are generally reddened with increased vascular markings, the normal landmarks are distorted with bulging of the membrane and loss of the light reflex. Pneumatic otoscopy reveals an immobile tympanic membrane, and if tympanometry is available would show a flattened curve.

Evaluation
Generally, a careful history with confirmatory physical examination is all that is needed to evaluate the child.

Treatment
Treatment of simple, uncomplicated otitis media is a 7-10 day course of antibiotics against the most common organisms (e.g. Strep. pneumonia, Moraxella catarrhalis, and Haemophilus influenza). Follow-up examination to document the resolution of the infection is generally advocated; the timing depends on the age of the child.

Complications of otitis media include:

• Chronic otitis media
• Hearing loss
• Mastoiditis
• Cholesteatoma
• Cavernous sinus thrombosis
• Chronic perforation.

These conditions should be referred to an otolaryngologist.

Acute Otitis Media Discussion

Clinical Presentation
Children with acute otitis media will typically present with one or more of the following symptoms:

• Fever
• Recent onset of irritability
• Anorexia
• Vomiting or diarrhea

Diagnosis is made by pneumatic otoscopy, examining the tympanic membrane for position, color, and degree of translucency and mobility. Characteristic of acute otitis media is an opaque tympanic membrane with a bulging contour, obscured landmarks, with limited or no mobility. A tympanogram may be obtained to assess mobility. Erythema of the eardrum is common. Middle ear effusion is a frequently associated finding but asymptomatic in itself. Otitis media with effusion will reveal air-fluid levels, serous middle ear fluid, and a translucent tympanic membrane with decreased mobility associated with negative pressure in the middle ear.

Pathophysiology
Otitis media is the most common diagnosis for illnesses in office practices for children. The most frequent occurrence is in the under 2 age group. Recurrent acute otitis media is defined as 3 isolated episodes of otitis media in 6 month, with resolution of each episode. Risk factors for recurrent acute otitis media include:

• Male gender
• Race
• Early occurrence of infection
• Sibling history
• No breast feeding

Most cases of otitis media occur in the under-6 age group. The reasons for this are based on changes in the immune system and the anatomy of the Eustachian tube. The angle of the tube changes from 10 degrees to 45 degrees from infancy to adulthood, and lengthens from 18-35 mm. Therefore, children generally have functional improvement with age. Other factors that contribute to Eustachian tube dysfunction are allergies and seasonal changes. Two common agents that have been identified are Strep. pneumoniae and Haemophilus influenzae.

Lab Findings
Lab tests are usually not necessary in the diagnosis of acute otitis media. Tympanocentesis is indicated in the following cases:

• Acute otitis media with poor response to antibiotics
• Suppurative complications from acute otitis media
• Acute otitis media in a newborn or child with primary or secondary immunodeficiency
• A child who is acutely ill/septic

Blood cultures are rarely helpful.

Imaging Findings
Computed tomography may be indicated when it is suspected the child has a suppurative complication such as mastoiditis or cavernous sinus thrombosis.

Pathology
See Pathophysiology above.

Differential Diagnosis
See Differential Diagnosis for The Approach to the child with ear pain

Treatment
The first line of defense is antimicrobial therapy, such as amoxicillin or ampicillin. A 10-day course is prescribed; if the patient does not improve, a broad-spectrum antibiotic such as erythromycin-sulfamethoxazole may be necessary. For patients allergic to penicillin, trimethoprim-sulfamethoxazole is used as a first-line defense. The ears should be re-examined in 10-14 days, but it should be recognized that patients will still have some persistent middle ear effusion. The treatment of recurrent acute otitis media is initially the same as acute otitis media, but may be followed by chemoprophylaxis, myringotomy with tympanostomy, or adenoidectomy with or without tonsillectomy. Otolaryngology should be consulted when the physician is uncertain about the appearance of the tympanic membrane by otoscopic examination and otomicroscopic examination is desired, or if the patient has a congenital condition associated with abnormal ear canals, such as Down syndrome or cleft palate. Pressure equalizing tubes placed surgically in the tympanic membrane may be helpful for children with recurrent acute otitis media.

Prognosis
Complications of acute otitis media can include:

• Perforation of the tympanic membrane due to increased pressure from the purulent material in the middle ear. This usually heals within a week with occasional scarring of the tympanic membrane.
• Temporary conductive hearing loss
• Acute mastoiditis - an infection extending into mastoid air cells
• Meningitis - usually due to concurrent infection with the same bacterial organisms.

References
Huddad Jr J. Treatment of acute otitis media and its complications. Otolaryngologic Clinics of North America 1994: 27(3), 431-441.

Illingworth, RS, Common Symptoms of Disease in Children. Blackwell Scientific Publications. 1988. pp.198-199.

Klein JD. Lessons from recent studies on the epidemiology of otitis media. Pediatric Infectious Disease Journal 1994: 13(11), 1031-1034.

Sheldon, Stephen H. and Levy, Howard B. Pediatric Differential Diagnosis. Raven Press. New York, 1985. pp. 126-28.

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