Pediatrics 14: 18-month-old female with congestion

User: Maryam Fadah

Email: 201315184@uaeu.ac.ae
Date: March 8, 2020 9:16PM

Learning Objectives

Perform an age-appropriate history and physical examination for a toddler with congestion, cough, fever
Generate an age appropriate differential diagnosis for a toddler with congestion, cough, fever
Describe the epidemiology, pathophysiology, clinical findings, and management of important causes of congestion, cough, fever
Describe the optimal sequence of elements of the physical exam in a toddler to maximize patient comfort and cooperation
Discuss key elements of the ear exam in a young child, including options for positioning and use of pneumatic otoscopy
List physical exam findings associated with a normal tympanic membrane, acute otitis media (AOM), otitis media with effusion
(OME), otitis externa
List risk factors, common pathogens, and potential complications associated with acute otitis media
Summarize current guidelines for diagnosis and management of acute otitis media
Identify possible language delay in a toddler
Discuss options for assessment of hearing in young children
Summarize recommendations for management of otitis media with effusion

Knowledge

Description of ear findings

A normal middle ear generally has a translucent tympanic membrane (TM) that is in a neutral or retracted
Normal ear position.

It has normal mobility.

Otits media Bilateral otitis media with effusion (OME) is best described as fluid in the middle ear space without signs and
with effusion symptoms of acute inflammation (bulging or fullness of the tympanic membrane, fever and/or otalgia).

Otitis externa, also known as "swimmer's ear," is manifested by an edematous external auditory canal, and
Otitis pain with traction on the ear lobe.
externa
An external otitis can occasionally follow perforation of the TM in AOM.

A diagnosis of acute otitis media is supported by moderate or severe bulging of the tympanic membrane;
Acute otitis OR mild bulging in the context of recent onset of pain or intense erythema of the TM.
media AOM should not be diagnosed in the the absence of middle ear effusion, as determined by pneumatic
otoscopy or tympanometry.

Risk factors for acute otitis media

Risk factors for acute otitis media (AOM) include:

Day care attendance

Tobacco exposure
Allergies
Bottle propping at bedtime
Pacifier use
Drinking formula from a bottle rather than breastfeeding
Significant family history of AOM
Male gender
Lower socioeconomic status
Respiratory allergies

Children with conditions affecting craniofacial structure (cleft palate, Down syndrome) and genetic predisposition (Native
Americans) are also at greater risk.

Bacterial Organisms in AOM

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 Bacterial causes of AOM are found in the following percentages:

Streptococcus pneumoniae 25-50%

Haemophilus influenzae, nontypeable 15-52%

Moraxella catarrhalis 3-20%

Streptococcus pyogenes < 5%

Recent data from population groups well immunized with the heptavalent Streptococcus pneumoniae vaccine have shown a shift
toward a higher prevalence of nontypeable H. influenza than S. pneumonia isolated from the middle ear. Therefore, depending on
the populations assessed, either S. Pneumoniae or nontypeable H. influenzae are the two most prevalent organisms found in AOM.

Viruses in AOM

Viruses also play a significant role in the pathogenesis of otitis media:

Viruses are known either to alter the mucosal lining, thereby increasing bacterial colonization of the nasopharynx, or to act
as a sole pathogen in AOM.
When a virus is a co-pathogen with bacteria, the acute infection may be less responsive to antibiotic therapy.
Viruses known to be particularly associated with AOM are respiratory syncytial virus (RSV), influenza and rhinovirus.

Persistence of middle ear effusions after acute otitis media

Middle ear effusions may persist at these rates for several weeks or even months after treatment with antibiotics.

Percentage of
Duration
children

1 month 30-50%

2 months 15-25%

3 months 8-15%

Potential Testing Performed by an Audiologist

Tympanogram An objective method for evaluation of the mobility of the tympanic membrane.

Behavioral test measuring auditory thresholds in response to speech and frequency-specific stimuli
Conventional audiometry
presented through earphones.

Visual reinforcement Behavioral test measuring response of the child to speech and frequency-specific stimuli presented
audiometry (VRA) through speakers in a sound-treated room.

Otoacoustic emissions Physiologic test measuring cochlear function in response to presentation of a stimulus. Primarily used
(OAE) in newborn assessments.

Clinical Skills

Examination of a Toddler

It is helpful to develop a consistent sequence in the physical exam of a toddler:

1. Because a toddler is sometimes reluctant and/or uncooperative, general observations of the child's behavior, degree of
alertness, and interactions with her parents should be noted first.
2. A brief look at the eyes for conjunctival erythema or discharge is easier early on, in case the child cries with subsequent
evaluation.
3. Examine the heart, lungs, and abdomen before the ears and oral cavity. Otherwise, the child may become agitated, so that
palpating the abdomen and listening for lung and heart sounds becomes much more difficult.
4. Perform the most intrusive portions of the exam, examination of the ears and oral cavity, last.
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 The Ear Exam of a Toddler

The ear exam is often quite challenging for medical providers. While there are many possible positions in which to place the young
child for the ear exam, we suggest initially enlisting parent participation. Possible positions include holding against parent's chest,
supine on parent's lap, or parent holding arms on exam table.

Pull the pinna up and back, to help see past the anterior "bend" in the external auditory canal.

Place your hand close to the head of the otoscope, with the fifth finger or side of the hand against the child's face to guard against
sudden motion.

Pneumatic otoscopy (use of an otoscope and insufflation bulb), allows you to assess mobility of the tympanic membrane.

What to Look for in an Ear Exam

What you should look for in an ear exam:

C = Color (gray, white, red or yellow)

O = Other (bubbles, air-fluid interface, scarring, or perforation)

M = Mobility (absent, reduced, normal, or hypermobile)

P = Position (normal, retracted, or bulging)

T = Translucency (opaque or translucent)

At a minimum, you should be able to describe the color, position, and mobility.

Tympanic membranes white/red, reduced mobility, bulging, opaque:

Tympanic Membranes white/red, reduced mobility, bulging, opaque

Tympanic membranes amber/red, nonmobile, retracted position, opaque:

Tympanic membranes amber/red, nonmobile, retracted position, opaque

Tympanic membranes gray, normal mobility, neutral position, translucent:

Tympanic membranes gray, normal mobility, neutral position, translucent

Note about redness: One of the most common errors made by practitioners is to overuse "red color" in making the diagnosis of
an ear infection. An erythematous TM alone is a poor predictor of either middle ear fluid or AOM. Many things can cause a TM to
turn red, including fever and crying.

This is a normal tympanic membrane turning red when the child begins to cry. Position and mobility are more reliable predictors
than color for the presence or absence of middle ear disease.

Normal tympanic membrane turning red when the child begins to cry

Management

Antibiotic Therapy for AOM

Amoxicillin remains the preferred first-line therapy for AOM because at appropriate dosages it is effective against susceptible and
intermediately resistant S. Pneumoniae due to alterations in their penicillin-binding proteins. Amoxicillin also:

is inexpensive,
tastes good,
has a relatively good safety profile, and
is narrow in its spectrum of antibacterial activity.

The majority of cases of AOM resolve spontaneously. Treatment with antibiotics has been shown to shorten duration of symptoms
(otalgia).

Intratemporal complications of AOM occur rarely due to extension of the infection into adjacent structures. The most common of
these is mastoiditis, which occurs most commonly in children under age two. Additional complications may include facial nerve
palsy, labrynthitis, cholesteatoma formation, and CNS infection.

Benefits of antibiotic therapy have been shown to be greatest in children under age 2 and those with bilateral otitis media.
Accordingly, current practice guidelines recommend that all children age 6 months to 2 years old with bilateral

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 acute otitis media, regardless of severity of symptoms, should be treated with antibiotics.

The following algorithm summarizes treatment guidelines for children aged 6 months to 2 years with unilateral
acute otitis media, or children over 2 years with unilateral or bilateral acute otitis media.

In these cases, clinician and parent can discuss

Use antibiotic therapy in these cases:
antibiotic therapy vs. additional observation and close followup*

AOM with severe symptoms, defined as:

Toxic-appearing child, or AOM with mild symptoms, defined as:

Persistent ear pain for 48 hours, or Mild ear pain and

Fever > 39 C within the past 48 Temperature < 39 C in past 48 hours

hours

The observation option should be offered only to families in which good followup can be assured and antibiotics can be started
should the child's condition worsen or not improve in 48 to 72 hours.

Treatment of Persistent OME

American Academy of Pediatrics guidelines on the management of OME note that it is important to "distinguish the child with OME
who is at risk for speech, language, or learning problems from other children with OME..."

Children with persistent effusion for three months who have normal speech and language -- and no other risk factors for
hearing loss -- should have a hearing assessment. If the assessment is normal and there are no other risk factors, the child
can be followed at 3- to 6-month intervals until the effusion resolves.
Tympanostomy tube placement should be considered in children with OME persisting 4 months or longer and accompanied
by hearing loss, documented language or other developmental delay, risk of developmental delay, or structural abnormality
of the tympanic membrane or middle ear. Although anecdotal evidence suggests that tympanostomy tube placement can
have a short-term positive impact on hearing, frequency of episodes or acute otitis media, and quality of life, there is no
evidence that early placement of tympanostomy tubes in otherwise healthy children with persistent OME improves
developmental outcomes at 3, 4, 6, or 9-11 years of age.

Studies

Visual Reinforcement Audiometry (VRA)

VRA is an appropriate audiologic evaluation for children from about 6 months to 2.5 years of age, but requires a sound-treated
room and an experienced audiologist (i.e., it is not a useful screening tool). The child is put in a booth and is typically sitting on a
parent's lap. It is referred to as behavioral testing because it measures a child's response to both speech and frequency-specific
stimuli presented through speakers. Response to the stimuli is rewarded typically with a three-dimensional animated toy. This test
is not ear-specific, as it assesses hearing only in the better ear.

Conventional audiometry with headphones generally is not possible until the child is 4 years or older.

Clinical Reasoning

Diagnostic Considerations in a Child with Congestion, Cough, and Fever

Diagnosis Comment

Typically develops 3-5 days after onset of upper respiratory symptoms.

Acute otitis One of the more specific symptoms is otalgia (ear pain, tugging at ears).
media Other symptoms include fever, irritability, cough, anorexia, and, less commonly, vomiting and diarrhea.

Otitis media is a common complication of URIs in this age group.

Viral pneumonias often present with moderate fever, a nonproductive cough and gradual onset of upper
respiratory tract symptoms. Lung exam findings may include wheeze, and are often bilateral.

Bacterial pneumonia typically presents with the abrupt onset of high fever, cough, and ill appearance.
Pneumonia
Some children have chest pain. Bacterial pneumonia may be a secondary infection following recent URI.
Lung exam findings may be focal or subtle.

Important PE findings for pneumonia are tachypnea, dyspnea, crackles, decreased breath sounds.

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 Most episodes of sinusitis are thought to begin with a viral URI, followed by superinfection of pathogenic
bacteria (the same organisms as in OM).
Sinusitis
A diagnosis of sinusitis should be considered when symptoms are persistent (>10 days), worsening, or
severe (e.g. fever > 39 degrees).

Upper Depending on the viral agent, the presentation of the common cold is variable.
respiratory Throat irritation, sneezing, nasal stuffiness, rhinorrhea, cough, fever, and irritability are common symptoms
tract infection of a URI.

References

American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery and American Academy of
Pediatrics Subcommittee on Otitis Media with Effusion. Otitis media with effusion. Pediatrics 2004;113:1412-1429

American Academy of Pediatrics. Practice Guideline: Otitis media with effusion. Pediatrics . 2005;5:113.

Block SL et. al. Community-wide vaccination with heptavalent pneumococcal conjugate significantly alters the microbiology of acute
otitis media. Pediatr Infect Dis J. 2004;23: 829-833.

Casey JR et al. New patterns in the otopathogens causing acute otitis media six to eight years after introduction of pneumococcal
conjugate vaccine. Pediatr Infect Dis J. 2010: 29: 304-9.

Chonmaitree T, Owen MJ, Howie VM. Respiratory viruses interfere with bacteriologic response to antibiotics in children with acute otitis
media. J. Infect. Dis. 1990;162: 546-549.

Hagan JF, Shaw JS, Duncan P, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,Third Edition.
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Harlor AD, Bower C, The Committee on Practice and Ambulatory Medicine, The Section on Otolaryngology-Head and Neck Surgery.
Clinical Report - Hearing Assessment in Infants and Children: Recommendations Beyond Neonatal Screening. Pediatrics
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Heikkinen T, Ruuskanan O. Signs and symptoms: predicting acute otitis media. Arch Pediatr Adolesc Med. 1995:149;26-29.

Kaleida PH. The COMPLETES exam for otitis. Contemp Pediatr 1997;14:93-101.

Lieberthal, AS et al. The diagnosis and management of acute otitis media. Pediatrics . Published online Feb 25, 2013. Available at
http://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3488. Accessed May 25, 2016.

Paradise JL, et al. Effect of early or delayed insertion of tympanostomy tubes for persistent otitis media on developmental outcomes at
the age of three years. N Engl J Med 2001:344:1179-87.

Teel DW, Klein JO, Chase C, Menyuk P, Rosner BA. Otitis media in infancy and intellectual ability, school achievement, speech, and
language at age 7 years. Greater Boston Otitis Media Study Group. J Infect Dis 1990;162:685-694.

U.S. Food and Drug Administration. Public Health Advisory. Nonprescription cough and cold medicine use in children. FDA
recommends that over-the-counter (OTC) cough and cold products not be used for infants and children under 2 years of age.
http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm048682.htm. Published January 17, 2008. Updated October 10, 2008.
Accessed April 20, 2017.

Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in
children aged 1 to 18 years. Pediatrics. 2013 Jul 1;132(1):e262-80.

Wallace IF, Berkman ND, Lohr KN, Harrison MF, Kimple AJ, Steiner MJ. Surgical treatments for otitis media with effusion: a systematic
review. Pediatrics 2014, 133(2): 296-311.

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