A 5-year-old boy is brought to the office due to ear pain. Two days ago, the patient developed low-grade fever and pain in the left ear. His parents think he is also having trouble hearing from the left ear as they have noticed him tilt his right ear toward the television. For the past week, the patient has also had a runny nose and cough, which developed soon after the family flew home from vacation. He has no history of ear infections or other chronic issues and takes no medications. Temperature is 38.1 C (100.6 F), blood pressure is 110/60 mm Hg, and pulse is 110/min. Examination shows bulging of the left tympanic membrane, which is pale yellow and immobile with pneumatic insufflation. The right tympanic membrane and bilateral auditory canals appear normal. The nasal mucosa appears boggy, and postnasal drip is present. The maxillary and frontal sinuses are nontender. Which of the following is the most likely diagnosis in this patient?
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This child has acute otitis media (AOM), or infection of the middle ear fluid. Unlike older children and adults, young patients (particularly age 6-18 months) are predisposed to AOM due to narrower and straighter eustachian tubes. Additional risk factors include day care/school attendance, positive family history, and cigarette smoke exposure.
AOM often follows an upper respiratory infection, which causes inflammation and edema of the already narrow eustachian tube. Fluid accumulation in the distal tube allows for growth of colonized bacteria, most commonly Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis.
Common presenting symptoms include otalgia, fever, and irritability. In addition, patients may have conductive hearing loss, as seen in this child, because fluid in the middle ear inhibits sound transmission.
The most specific finding in AOM is a bulging tympanic membrane (TM) due to middle ear inflammation. Other classic findings include decreased TM mobility on pneumatic insufflation or visible air-fluid levels, both indicating middle ear effusion. A pale yellow, opaque TM with bulging is suggestive of purulent effusion. TM erythema is also common but is not required for the diagnosis; as an isolated finding (ie, no bulging or effusion), it is insufficient for diagnosis.
(Choice B) Barotrauma due to flying can occur if middle ear pressure does not equilibrate with atmospheric pressure during ascent/descent. Symptoms may include bleeding in the middle ear space (ie, hemotympanum) or TM rupture. This patient developed symptoms days after travel and has signs of acute inflammation.
(Choice C) Bullous myringitis is an uncommon complication of AOM and presents with TM bullae, which are not seen in this patient.
(Choice D) Cholesteatoma is an abnormal growth of squamous epithelium in the middle ear and presents with hearing loss and a white mass posterior to the TM, which is not seen in this patient. Fever and TM bulging would not be expected.
(Choice E) Chronic suppurative otitis media is characterized by otorrhea and hearing loss for >6 weeks and TM perforation on examination, findings not present in this patient.
(Choice F) Otitis media with effusion (OME) may cause hearing loss and poor TM mobility. However, in contrast to AOM, in OME, there is a lack of acute inflammation (eg, fever, TM bulging).
Educational objective:
Acute otitis media, a common cause of otalgia in young children, is characterized by middle ear inflammation (eg, tympanic membrane [TM] bulging ± erythema) and effusion (eg, poor TM mobility).