A 16-month-old female presents to the Emergency Department for evaluation of diarrhea and fever. She had been seen in Urgent Care the day prior and diagnosed with a viral illness and otitis media. The parents were instructed on supportive measures and a prescription for antibiotics was provided. Due to worsening diarrhea and concern for dehydration, she was brought in for re-evaluation. Her past medical history is significant for a completed course of antibiotics two weeks ago for an ear infection. She has otherwise demonstrated normal growth and development. In the emergency department, she is an afebrile, well-appearing toddler. She has a mild diaper rash. Her Wispr digital otoscope exam is shown.
How would you instruct the parents?
Continue the course of antibiotics prescribed yesterday.
Consult to ENT
Hold the prescribed antibiotic and provide continued supportive measures
4. Hold the prescribed antibiotic and provide continued supportive measures
The importance of good ear drum visualization for diagnosis is clear in this case. A 16-month-old child can be a particularly challenging exam. The features of the Wispr otoscope, particularly the thin speculum, increase the chances of successful imaging such as in this case.
The child’s Wispr exam does not demonstrate any of the hallmarks of active acute otitis media (AOM) to support the need for antibiotics. Specifically, she does not demonstrate moderate to severe bulging, mild bulging with concomitant intense erythema or bullae. However, her tympanic membrane does show evidence of a recent acute otitis media (AOM). First, there is a bulging of the pars flaccida portion of the tympanic membrane (TM). Second, she has several whitish spots consistent with dried purulence, “mud spots,” adherent to the middle ear surface of the TM, likely from a prior AOM. These findings (not to mention the gastrointestinal side effects of antibiotics) support the recommendation to hold the antibiotics, apply barrier ointment for the diaper rash, and encourage supportive measures for her likely viral gastroenteritis. Careful return instructions should also be provided.