An 18-month-old female is brought into the emergency department (ED) with concerns for vomiting, fever, and fussiness. The child had historically been well and is age-appropriate vaccinated. The symptoms began 2 days earlier. Symptoms initially included pulling at the ears, escalating to vomiting, poor feeding, and fever to 103 F. The parents treated the child with antipyretics but became concerned when the child seemed to be declining further. They brought her to the ED with a primary concern of dehydration. In the ED, she was found to have a brisk capillary refill, elevated heart rate and a fever of 102 F. Influenza and COVID tests were both negative. Urinalysis was also negative. This image of her right ear was obtained.
Would you start the child on antibiotics based on the history, exam, and imaging presented?
The child has Otitis Media with Effusion (OME)
Antibiotics are not indicated based on the imaging obtained from the right ear.
The right ear is not normal. The abnormality is the air-fluid levels in the middle ear space. However, there is no bulging of the tympanic membrane (eardrum), and the malleus ossicle is discernable. All of these features indicate a properly functioning Eustachian tube, which drains and ventilates the middle ear space to the posterior nasal pharynx. The air-fluid levels are from inflammation, likely from a viral syndrome based on the child’s history and exam.
Day 0 right ear exam with annotation showing middle ear effusion (MEE)
This is the same patient as presented in this case where the other ear, the left ear, did progress to acute otitis media (AOM). You can see on the annotated image below the striking difference.
Compare the annotated right ear (above) and left ear (below). There is an obvious difference between a MEE and AOM.
Day 1 left ear exam with annotation showing acute otitis media (AOM)