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The most likely diagnosis for a child with fever and ear pain who has a bulging, opaque, erythematous tympanic membrane with impaired mobility is


acute otitis media


Otitis media with effusion (OME) can be defined as


effusion within the middle ear without evidence of infection.


Cholesteatoma is


an accumulation of squamous epithelial cells, usually visible as a discrete white mass behind the TM, which can be congenital or acquired, most commonly
in the setting of chronic otitis media.


A 7-year-old boy presents for a hearing evaluation. His mother reports that for the
past few months, he has been listening to music and television at higher volumes.
His teacher has moved his seat to the front of the classroom because of perceived
hearing difficulties. He had middle- ear infections at ages 2 and 3 years. He has been
in good health since then and does not have any current ear pain, fevers, or upper
respiratory symptoms.
He appears well and is afebrile. His vital signs are within normal limits. The right ear
is examined otoscopically (figure).


The most likely diagnosis in a child who presents with hearing loss and is found
to have a white mass behind an intact eardrum is cholesteatoma.


what is the first line and second line treatment and third line treatment of acute otitis media? most common cause?


The bulging, erythematous appearance of this child’s tympanic membrane
suggests a diagnosis of unilateral AOM.
Streptococcus pneumoniae is the most common bacterial cause.

Intramuscular ceftriaxone can be used to treat recurrent AOM but is not a first-line
therapy because it is a more broad-spectrum antibiotic than amoxicillin, and it is
more challenging to administer. In recurrent AOM, three doses of intramuscular
ceftriaxone have been shown to be superior to one for eradicating penicillinresistant S. pneumoniae from the middle ear.

Amoxicillin–clavulanate is not considered first-line therapy for uncomplicated
AOM. It should be reserved for infections not responding to amoxicillin and can be considered in children with more complicated cases, such as those with multiple
prior infections or AOM with acute tympanic membrane perforation.

Azithromycin is not recommended for treatment of AOM unless the child has a
well-documented amoxicillin allergy.


explain management acute otitis media?


Given that she has had a fever >39°C,
antibiotics are required. First-line therapy consists of a 10-day course of highdose amoxicillin (90 mg/kg/day divided into two doses per day) because

For children older than 6 months who have unilateral AOM, mild symptoms, fever
<39°C, and normal immune systems, a wait-and-see approach to antibiotic
therapy should be discussed with parents as an option. If this approach is
implemented, close follow-up should be arranged for 48 to 72 hours after initial
diagnosis or a prescription for antibiotic therapy should be provided, but
caregivers should initiate therapy only if symptoms persist or worsen (increased
ear pain, temperature >39°C). Children with bilateral disease can be offered
watchful waiting if they are at least 2 years of age, but those younger than 2 years
should be treated.


When sound conducted through air is abnormal but sound conducted through bone is normal, the diagnosis is


conductive hearing loss.


Bilateral otitis media with effusion
leads to


conductive hearing loss by preventing the tympanic membrane from vibrating appropriately and transmitting sound through the ossicles to the cochlea via the oval


Congenital deafness is


usually familial and nearly always sensorineural; connexin 26 mutations are the most common cause.


Vestibular schwannoma can occur in patients with


neurofibromatosis type 2 and would lead to sensorineural hearing loss.


Aminoglycosides, such as gentamicin, are toxic to


cochlear hair cells and can lead to sensorineural hearing loss.


Bacterial meningitis is a common cause of


acquired sensorineural hearing loss.


The most appropriate screening strategy for hearing loss in an infant who passed
her newborn hearing screen but has risk factors for hearing loss is


repeat formal diagnostic audiologic assessment by 24 to 30 months of age.


Otoacoustic emission screening is routinely used to screen


healthy newborns and
is commonly used for office-based hearing screening. It uses a small signal to
stimulate the hairs in the cochlea to obtain a response. However, it is not an
adequate screening test for children with risk factors for hearing loss.


Conventional screening audiometry requires that


the patient be able to reliably
understand and follow instructions; thus, it is not appropriate for children younger
than 4 years of age


what is the difference between cholesteatoma and middle ear effusion


Cholesteatoma is a less common complication of recurrent otitis media than
middle-ear effusion. Children with cholesteatoma present with unilateral
conductive hearing loss, chronic ear drainage, and an abnormal otoscopic
examination (with a pearly white mass observed behind the tympanic membrane,
a retraction pocket, or an area of granulation tissue at the periphery of the
membrane). Prior placement of tympanostomy tubes increases risk.


what does this child have?
A 4-year-old girl is evaluated for behavioral difficulties. She is enrolled in preschool
but has been having trouble following instructions in the classroom. At home, she
does not come when called, and she ignores her mother’s requests. It is difficult for
strangers to understand most of what she says. She gets frustrated easily and has
temper tantrums.
She was born full term with no complications in the newborn period. Her newborn
hearing screen was normal. She has had four episodes of otitis media during the
past 6 months; they have been treated with oral antibiotics.
Tympanometry screening in the office shows bilateral flat lines. On audiometry, bone
conduction is better than air conduction bilaterally


middle-ear effusion


what does this guy has and how to treat hem?

A 17-year-old boy presents for evaluation of severe pain, itching, and yellow drainage
in his left ear. He has been working as a summer camp counselor and has no
significant medical history. His current symptoms started about 24 hours ago in the
absence of any trauma.
He has a body temperature of 36.9°C, a respiratory rate of 16 breaths per minute,
and a heart rate of 76 beats per minute. External ear examination reveals tenderness
on palpation and tugging of the left pinna, but no erythema or edema. Otoscopy
reveals a red, swollen ear canal containing yellow debris. The debris is gently
removed. Visualization of the tympanic membrane is partially obscured by ear-canal
edema. There are no visible air-fluid levels along the tympanic membrane, and
insufflation reveals that the tympanic membrane is mobile. There is no periauricular
edema or cervical lymphadenopathy. The rest of the physical examination is normal.


This patient’s presentation and history are consistent with uncomplicated acute
otitis externa (AOE), a cellulitis of the ear canal, skin, and subdermis.

Ciprofloxacin 0.2%–hydrocortisone 1% otic solution to the
affected ear twice daily

The most appropriate treatment for uncomplicated acute otitis externa in an otherwise healthy adolescent is a topical antibiotic–glucocorticoid combination or a topical antiseptic.


symptoms of acute otitis externa include ear pain, itching, discharge, and
tenderness to the touch. Hearing loss is typically mild and only occurs later in the
infection, when ear-canal swelling blocks the canal. This presentation is distinct
from that of acute otitis media, where ear pain is initially severe but the ear is not
tender to the touch, and hearing diminishes almost immediately as the ear drum
swells and the middle ear fills with fluid.
Patients with AOE typically have a swollen and moist ear canal. The ear drum may
be difficult to see but is usually normal, and the middle ear is aerated.
Examination with an otoscope is usually painful for these patients. In contrast, in
patients with acute otitis media, the ear canal is normal-sized and nontender, the
ear drum is red and bulging, and the middle ear will have fluid or pus. If the ear
drum ruptures, a perforation may be visible, but it may also be very difficult to see
through the drainage. The differential for acute ear pain with debris in the canal
includes both ruptured otitis media and otitis externa, so the presence of edema
in the canal, the demonstration of pain with tugging the ear lobe, and (whenever
possible) the gentle removal of debris are all helpful to establish the diagnosis. In
some patients, the debris will need to be cleared by an otolaryngologist using
binocular microscopic guidance.
In severe cases of acute otitis externa, the infection may spread to the auricle and
surrounding structures with erythema, edema, tenderness, and often upper
cervical adenopathy. Such spread is rarely seen in acute otitis media.
The recommended treatment for uncomplicated acute otitis externa is either a
topical antiseptic, such as acetic acid, or a topical antibiotic–glucocorticoid
combination, such as ciprofloxacin–hydrocortisone. The antibiotic component of

the combination should ha associated with otitis externa: ve activity against the two bacteria most fr Staphylococcus aureus and Pseudomone
Topical treatment for uncomplicated otitis externa is preferred over ora
because it delivers a high concentration of medication to the affected
minimal systemic adverse effects. A 2010 meta-analysis revealed no s
differences among topical antibiotic agents with respect to clinical or
microbiologic cure rates; there was a suggestion that adding a high-po
glucocorticoid to the topical antibiotic could reduce swelling, but the m
of a possible effect could not be determined with the data available.
Topical antiseptic alone (alcohol–acetic acid) will not be sufficient for
bacterial component in this patient’s ear (as evidenced by yellow disch
edema, and erythema).
Topical antibiotic cream or ointment such as mupirocin is helpful in ca
infection caused by methicillin-resistant S. aureus, but this diagnosis d
with the clinical picture of acute otitis externa in this patient.
Topical antifungals (e.g., clotrimazole) are not appropriate for treating
externa unless the cause is known to be fungal or standard therapy fa
infection can occur in up to 10% of patients with otitis externa, but it us
manifests with either white debris (in the case of Candida) or grey cha
(with Aspergillus) and is not usually severely painful.