An 18-month-old boy is brought to the clinic because he has been pulling on his ears. Two weeks ago, the patient was taken to an urgent care center for fever and irritability and was found to have acute otitis media of the right ear. He completed the prescribed course of amoxicillin, with resolution of symptoms. However, for the past few days, the patient has been tugging at both of his ears, and his parents are concerned that he may have another ear infection. Temperature is 36.8 C (98.2 F). On otoscopic examination, air-fluid levels are visible posterior to both tympanic membranes, which appear translucent and gray. Pneumatic insufflation demonstrates reduced mobility of tympanic membranes bilaterally. Both external ear canals are clear. The remainder of the examination is unremarkable. Which of the following is the best next step in management of this patient?
Show Explanatory Sources
This patient has otitis media with effusion (OME), defined by middle ear fluid without tympanic membrane (TM) inflammation (eg, bulging, erythema). Young children, particularly age 6-24 months, are predisposed to fluid accumulation within the middle ear due to narrow, straight eustachian tubes that drain poorly. Most effusions develop in the setting of a viral infection or following an episode of acute otitis media.
OME is typically asymptomatic but may cause mild discomfort (eg, ear tugging and pulling, as seen in this patient) due to pressure on the TM. Because the effusion limits TM vibration, conductive hearing loss is also common. OME does not cause fever or severe ear pain. Physical examination reveals air-fluid levels posterior to the TM and poor TM mobility on pneumatic insufflation. In contrast to acute otitis media, the effusion in OME is nonpurulent, and the TM is not bulging or erythematous.
OME usually resolves within weeks and does not require treatment. However, patients should be observed with follow-up for resolution because chronic OME (>3 months) can cause speech delay and long-term hearing loss. Tympanostomy tube placement is warranted for chronic OME with associated hearing loss (Choice E).
(Choice A) Patients with persistent or recurrent acute otitis media have TM bulging with middle ear effusion and are treated with an additional antibiotic course. This child has no signs of TM inflammation and therefore does not have acute otitis media.
(Choices B and C) Intranasal glucocorticoids and/or decongestants do not decrease the duration of OME and are therefore not indicated. Although oral glucocorticoids are associated with shorter OME duration, they are also not recommended because rates of speech delay and long-term hearing loss are unchanged.
Educational objective:
Otitis media with effusion (OME) is defined by middle ear fluid without tympanic membrane (TM) inflammation (eg, bulging, erythema). Examination shows air-fluid levels and poor TM mobility. Management is observation with follow-up for resolution because chronic OME is associated with speech delay and long-term hearing loss.