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CASE 20.1

A 2-year-old is brought to your office by her mother who is concerned that she has been pulling at her left ear since late last night and has a fever of 101.3°F. She has had recurrent bouts of these symptoms, the last of which was 9 months ago. Each time, the symptoms resolved with one "shot." She is alert and interactive. She has some evidence of mucoid discharge from her nares bilaterally.

Question 20.1.1 Each of the following findings is diagnostic of acute otitis media (AOM) EXCEPT:

A) Profuse, purulent ear discharge without other evidence of otitis externa.

B) Air–fluid level behind the tympanic membrane (TM) with marked redness of the TM and poor movement with pneumatic otoscopy.

C) Bulging, thickened yellow and red TM that does not move well with pneumatic otoscopy.

D) Bubbles in fluid behind the TM with impaired mobility of the TM on pneumatic otoscopy.

E) Yellow, opaque TM, poor movement with pneumatic otoscopy, and substantial ear pain.

Answer 20.1.1 The correct answer is "D." Suspected ear infections drive many parents to bring their children to a family physician. There may be fluid in the middle ear that is not infected (otitis media with effusion [OME]). In order to diagnose AOM, you need evidence of fluid in the middle ear and inflammation, and the symptoms should be acute (starting in the last few days). Middle ear effusion is diagnosed by (1) bubbles and/or air–fluid level behind the TM or (2) two or more of the following: decreased or absent TM movement with pneumatic otoscopy, opacification of the TM, and discoloration of the TM (yellow, white, blue). These findings get you to OME but not AOM. To diagnose AOM, you will need to have OME with evidence of acute inflammation, such as marked pain, thickened and/or bulging TM, and reddened TM. For these reasons, "B," "C," and "E" are examples of AOM. "A," purulent otorrhea without evidence of otitis externa, would be the one exception where you can diagnose AOM without even seeing the TM. "D" describes OME without inflammation.


Don't believe a red eardrum. By itself, redness of the TM has a 15% positive predictive value for diagnosing AOM. Use pneumatic otoscopy, which is the standard of care for diagnosing AOM. Tympanometry is an alternative to pneumatic otoscopy. Of course, you still need to look in the ear.

Your patient's left TM is opaque, red, and immobile upon pneumatic otoscopy.

Question 20.1.2 Each of the following factors increases her risk for developing otitis media EXCEPT:


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