A 3-year-old boy is brought to the pediatric clinic with 2 days of fever, irritability, and tugging at his right ear. His mother reports that he had an upper respiratory infection one week ago with nasal congestion and cough. Past medical history is negative. Vital signs show a temperature of 38.9°C (102°F) but are otherwise normal. Otoscopic examination of the right ear shows a bulging, erythematous tympanic membrane with decreased mobility on pneumatic otoscopy. The left ear is normal.
Which of the following is the most appropriate initial management?
The correct answer is:
A) High-dose amoxicillin therapy
This child has classic acute otitis media (AOM), characterized by acute onset of symptoms (fever, ear pain, irritability), middle ear effusion, and signs of inflammation such as a bulging, erythematous tympanic membrane with decreased mobility. AOM commonly follows a viral upper respiratory infection, which leads to eustachian tube dysfunction and bacterial superinfection. First-line treatment for uncomplicated AOM in children is high-dose amoxicillin, which provides adequate coverage for the most common pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
Answer choice B: Intranasal corticosteroids, is incorrect. Intranasal steroids may be used for allergic rhinitis but do not treat bacterial middle ear infections.
Answer choice C: Oral antihistamines, is incorrect. Antihistamines do not improve outcomes in acute otitis media and may cause adverse effects such as sedation.
Answer choice D: Reassurance and observation only, is incorrect. Observation may be appropriate in select older children with mild symptoms, but this patient is young and has significant fever and exam findings consistent with bacterial AOM. Watchful waiting may be appropriate for children over 6 months of age with mild symptoms.
Answer choice E: Topical antibiotic ear drops, is incorrect. Topical drops are used for otitis externa or for otorrhea in patients with tympanostomy tubes, not for uncomplicated AOM with an intact tympanic membrane.
Key Learning Point
Acute otitis media presents with fever, ear pain, and a bulging, immobile tympanic membrane. First-line treatment in young children with high fever, severe pain, or symptoms lasting longer than 48-72 hours is high-dose amoxicillin.
