A 2-year-old boy is brought to the office for follow-up. He was last seen 3 weeks ago for an episode of acute otitis media with symptoms of fever, crankiness, runny nose, and ear pain. Prior to this, he was healthy with no chronic medical conditions and with growth and developmental milestones appropriate for age. Examination at that time showed copious clear rhinorrhea and a bulging, erythematous right tympanic membrane. The patient was prescribed a 10-day course of amoxicillin. His mother reports that he has completed the course and his symptoms have improved: Fever has resolved, he no longer is cranky or indicates ear pain, and his appetite and activity level have returned to baseline. He has had occasional nasal congestion but no cough. Temperature is 36.7 C (98 F), pulse is 106/min, and respirations are 18/min. The patient is awake, alert, and in no acute distress. The head is normocephalic and atraumatic. The pupils are equal and reactive with normal fundi. The nares are patent with clear rhinorrhea; there is no erythema or exudate in the pharynx. The left tympanic membrane is normal; the right tympanic membrane is slightly retracted with yellow fluid behind the membrane and decreased mobility on pneumatic otoscopy. The neck is supple without lymphadenopathy. S1 and S2 are normal without murmurs. The lungs are clear to auscultation bilaterally. There are no rashes or skin lesions. What is the most appropriate next step in management of this patient?
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This child was treated for a recent episode of acute otitis media (fever, ear pain, red/bulging tympanic membrane) and currently is asymptomatic, with new findings of a retracted tympanic membrane with yellow fluid and decreased mobility. These findings are characteristic of an effusion in the middle ear, referred to as serous otitis media (SOM) or otitis media with effusion. After appropriate treatment of an acute episode of otitis media, an effusion (SOM) may persist in the middle ear for up to 3 months.
If no other symptoms are present at diagnosis, watchful waiting is indicated, as spontaneous resolution is likely to occur. If other symptoms (eg, fever, pain, purulent effusion) are present, if effusion is bilateral, or if effusion persists for >3 months, further therapy should be considered.
(Choice A) Amoxicillin-clavulanate is indicated in cases of recurrent or resistant acute otitis media. This patient improved after amoxicillin therapy. Antibiotic administration generally has no effect on the natural history of SOM.
(Choice B) Antihistamines and decongestants do not speed resolution or improve outcome in patients with SOM. In addition, many of these medications are not indicated in young children (age <6) due to the risk of side effects.
(Choice C) Audiometry is generally unnecessary unless effusion has persisted for >3 months. The exception is high-risk children (eg, those with developmental delays or speech disorders).
(Choice D) Myringotomy with insertion of tympanostomy tubes is a more invasive form of management that should be considered only if SOM does not resolve after an appropriate period of watchful waiting.
Educational objective:
After appropriate treatment of an acute episode of otitis media, serous fluid may persist in the middle ear for up to 3 months, referred to as serous otitis media. The effusion generally resolves spontaneously within 3 months; therefore, watchful waiting is the recommended management, unless there are persistent symptoms of infection, the effusion is bilateral, or >3 months have elapsed since the initial episode.