Otitis Media with Effusion – February 29, 2024
A 9-month-old female presents to the emergency department (ED) with her parents with concern for “many ear infections” and to obtain a second opinion. The parents state the child has been on antibiotics three times in the past four months and was prescribed another antibiotic earlier in the day when she was evaluated in Urgent Care. They report the child has an upper respiratory infection, but no fever. Her last ear infection was two weeks earlier and she was treated with a “white antibiotic.” In Urgent Care, her parents felt the ear exam was a struggle and wanted to be sure another course of antibiotics was necessary. They also report their daughter has a diaper rash and struggles with GI issues. In the ED, the child is afebrile and well-appearing. She has mild nasal congestion but clear lung sounds and no increased work of breathing. She has a beefy red rash in her diaper area.
Her Wispr digital otoscope exam is shown.
What is the appropriate course of action:
- Reinforce the need for taking the oral antibiotic prescribed in the Urgent Care.
- Stop the oral antibiotic and recommend an intramuscular antibiotic instead.
- Stop the antibiotic and treat her diaper rash with topical antifungal.
- Recommend immediate referral to ENT for tympanostomy tube placement.
Answer: C. Stop the antibiotic and treat her diaper rash with topical antifungal.
This child has a somewhat cloudy middle ear effusion (MEE) as evidenced by multiple air-fluid levels visualized on her Wispr exam. Air-fluid levels generally indicate that the middle ear space is being ventilated by the Eustachian tube. While the lateral process is slightly obscured, one can easily make out the length of the malleus and there is no “donut sign” to indicate moderate to severe bulging. Furthermore, the tympanic membrane (TM, “ear drum”) is nicely translucent without intense erythema. Thus, this child does not have acute otitis media (AOM) and her diagnosis is most consistent with otitis media with effusion (OME). She does not require antibiotics but ought to have her diaper-area candidiasis treated with a topical antifungal. Tympanostomy (“ventilation, ear”) tubes are indicated with recurrent AOM.
This case was notable for the challenging exam encountered in Urgent Care. Note the initial view below. This would be all a traditional otoscope would have seen given the wax burden. The Wispr digital otoscope is able to navigate around the wax to give a diagnostic view. See the complete video at the end of this case to appreciate this navigation.
Cerumen (wax) burden in the external ear canal
A partial and fleeting view of the TM could easily be misdiagnosed as AOM requiring antibiotics. Fortunately, after reviewing the Wispr images with the parents, they left the ED confident that—at this time—their daughter did not have AOM but should make note of the MEE so their primary care physician can make sure it has cleared within three months (which nicely aligned with her 12mo health-maintenance visit).
WiscMed has created a handy visual diagnosis of ear conditions that can be found here.
Here is the complete video exam.
