med 18

 

OTITIS MEDIA

TREATMENT

Antibiotics are not recommended in OME. Analgesics

should be given if the child has pain associated with the

middle ear effusion.

In children <2 years of age, oral antibiotic therapy is

indicated in AOM because ear infections in this age group

are less likely to resolve without antibiotic therapy. For

children �2 years of age with uncomplicated AOM, a

"wait-and-see" approach to treatment is an option. Because

many cases of AOM will resolve without antibiotic therapy,

the parent is given a prescription for antibiotics to be given

to the patient if symptoms worsen or do not improve in

48-72 hours. Ear pain should always be managed with

analgesics as needed, regardless of the therapeutic approach

taken. Analgesics for ear pain include oral ibuprofen and

acetaminophen as well as topical benzocaine/antipyrine

drops. Topical analgesics should not be given if there is

concern for a perforated TM.

If antibiotic therapy is chosen, high-dose amoxicillin

(80-90 mg/kg/day divided BID) is recommended as firstline treatment for uncomplicated AOM. Treatment duration is 10 days in children <2 years of age and can be

shortened to a 5-7 day course in children >2 years of age

with uncomplicated infections. Amoxicillin-clavulanate

(90/6.4 mg/kg!day divided BID) may be needed to treat

�-lactamase producing H. influenzae and M. catarrhalis

and should be used for AOM not responsive to amoxicillin. In addition, it may be considered as initial therapy in

Ear pain, fever, otorrhea, irritabil ity

Age > 2 years,

uncompl icated

AOM

"Wait-and-see"

prescription

No antibiotics

Consider

alternative

diagnosis

Figure 52-3. Otitis media diag nostic algorithm. AOM, acute otitis media; CT, computed

tomography; OME, otitis media with effusion; TM, tympanic membrane.

CHAPTER 52

children with severe disease (fever >39°C or severe ear

pain). Cephalosporins ( cefdinir 14 mg/kg/day in 1-2 doses,

cefuroxime 30 mg/kg/day divided bid, cefpodoxime

10 mg/kg/day once daily) may also be used for treatment

failures. Ceftriaxone (50 mg/kg intramuscularly or intravenously) may be used to treat AOM in a patient with

vomiting and an inability to tolerate oral medications. A

single dose is adequate for initial treatment; 3 doses over

3 days are recommended for treatment failures. For patients

with a penicillin allergy, a third-generation cephalosporin

should be given if it is a non-type I hypersensitivity. With

a type I hypersensitivity to penicillins, options include

clindamycin, macrolides, erythromycin-sulfisoxazole, and

trimethoprim-sulfisoxazole, but all provide suboptimal

coverage.

DISPOSITION

..... Admission

Only children with complications of AOM, such as

mastoiditis or other intracranial complications, require

hospitalization.

..... Discharge

Non-toxic-appearing children without complications of

AOM may be discharged home. Discharge instructions

should be clear, especially if using a "wait-and-see"

prescription for antibiotics, and should always include

treatment of ear pain with analgesics as needed. Patients

should be instructed to follow up with the primary care

provider if symptoms do not improve in 48-72 hours or

earlier if symptoms worsen or there are signs or symptoms

of complications of AOM.

SUGGESTED READING

AAP Clinical Practice Guideline. Diagnosis and management of

acute otitis media. Pediatrics. 2004;1 13:1451-1465.

AAP Clinical Practice Guideline. Otitis media with effusion.

Pediatrics. 2004;1 13:1412-1429.

Spiro DM, Arnold DH. Ear and mastoid disorders in infants and

children. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM,

Cydulka RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY: McGrawHill, 201 1.

Pharyngitis

S. Margaret Pa i k, MD

Key Points

• Disti nguish potentially life-threatening (epiglottitis,

peritonsillar, and retropharyngeal abscess) and benign

(uncompl icated pharyngitis) conditions.

• Use a scoring system to guide management of

pharyngitis.

INTRODUCTION

Sore throat is a common complaint seen in the emergency

department (ED). Pharyngitis is inflammation of the throat

and is usually the cause of sore throat. Inflammation of the

tonsils (ie, tonsillitis) may also be present. The goal of the initial evaluation of patients with a complaint of sore throat is to

exclude the most serious conditions (eg, abscess, epiglottitis).

Infectious pharyngitis involves direct invasion of the

pharyngeal mucosa by bacteria or viruses leading to a local

inflammatory response. Viruses are the most common

cause of pharyngitis and include adenovirus, parainfluenza,