Variations of "Doctor, she's been pulling on her ears again!" are voiced throughout hospitals and clinics multiple times a day. During pediatric residency, one of the continuing challenges is learning to diagnose and manage conditions affecting the ears of patients. In this article, I discuss some of the lessons I have learned.
In the outpatient setting, acute otitis media is by far the most commonly diagnosed acute ailment. In the United States, roughly 30 million office visits are made to primary care providers at a cost of more than 5 billion dollars annually. However, other maladies of the middle and the outer ear, such as otitis media with effusion, otitis externa, and aural foreign bodies, are frequently seen by the pediatric resident as well.
"Is a red tympanic membrane good enough to make the diagnosis?" I have found that developing the clinical skill to accurately diagnose acute otitis media challenges many medical students and residents. It is difficult to gain the cooperation of many patients, and, often, ear wax is the next daunting obstacle in the examination of the ear! However, once the tympanic membrane is visualized, the task of trying to determine what qualifies as acute otitis media confronts the examiner.
I remember multiple times coming to my attending physicians to present a patient, not knowing exactly how to describe what I saw. Terms describing color, shape, texture, and mobility become part of the vocabulary used in ear examination. Because proficiency with pneumatic otoscopy is requisite for identifying acute otitis media, it is a physical examination skill that should be demonstrated to medical students and residents and not laid aside because an insufflator bulb cannot be located. Learning to recognize that the middle ear space behind the tympanic membrane is filled with fluid and that membrane mobility is decreased requires patience on the part of the attending physician, the resident, the medical student, the patient, and the family. Crying children have red tympanic membranes, but may not have acute otitis media.
After the diagnosis of acute otitis media has been made, several questions arise. Should I treat with medications? What medications should I prescribe? What medications can I prescribe? Should I know how to perform tympanocentesis? If this is the fifth episode of acute otitis media in a year for the patient or if middle ear fluid has been present for several months, should I provide antibiotic prophylaxis? When do I call my otorhinolaryngology colleagues for placement of tympanostomy tubes? As I complete residency training, answers are being provided to each of these questions. Yet, I am certain that many of these answers will change.
Antibiotic choices are ever changing, thanks to the industriousness of the offending bacterial organisms, the pharmaceutical companies, and the third-party payers. By the end of a core pediatric clerkship, our medical students can list the common causative bacteria without taking a breath - Streptococcus pneumoniae, nontypable Haemophilus influenzae, and Moraxella catarrhalis. Most recently, the multidrug resistance of S. pneumoniae and beta-lactamase-producing non-typable H. influenzae has led to a reexamination of the recommendations for drug choice. After acetaminophen, amoxicillin quickly becomes the resident's closest ally in the formulary. What is different now from when I started training is the dosage and duration of therapy. The phrase "highdose amoxicillin" (referring to the dose of 80 mg/kg/d rather than 40 mg/kg/d) is heard in our clinics; the acceptance of this therapy has grown as understanding of degrees of resistance increases.
Nonetheless, there are 15 other drugs on the market approved by the Food and Drug Administration for acute otitis media. Residents face parental, attending, and pharmaceutical pressure on a daily basis. Choosing a drug and defending that choice, with insight into patterns of efficacy, susceptibility, and resistance, is becoming commonplace for residents.
Regarding antimicrobial prophylaxis of recurrent acute otitis media and otitis media with effusion, in the past few years I have seen a shift away from this practice. Concerns about increasing resistance and scattered reports of lack of efficacy in this practice have swayed us away from daily dosing of preventive antibiotics. Instead, it has become more common to proceed quickly to recommending the insertion of tympanostomy tubes. Nationwide, there has been an increase in the number of tubes being placed.
Myringotomy and tympanocentesis are not procedures I have learned to do during residency. Despite the understanding that effective management of a child with persistent middle ear fluid should include identifying the organism and its susceptibility pattern, it seems that few pediatric residents are trained in tympanocentesis. The questions of whether we should be and, if so, how, need to be addressed.
We make referrals to our otorhinolaryngologist colleagues for tympanostomy tube placement based on several recommendations, most commonly four or more recurrent episodes of acute otitis media in a year or chronic otitis media with effusion. Tubes do make an appreciable difference in the occurrence of middle ear disease in children, and I leave residency planning to incorporate them into therapy for these diseases.
Finally, what is the impact of otitis media on childhood development? This question is seldom raised by physicians in our busy urgent care settings. More often, parents have made me worry about this. Learning to interpret tympanograms and audiograms and making use of audiology should be encouraged. It will be interesting to see the results of the ongoing study at Children's Hospital of Pittsburgh that addresses these concerns of childhood development and otitis media. The cost of middle ear disease may prove to be more than economic in nature.
"There's gooey stuff in my ear." Each summer, several children come to the clinics with this complaint. Often, they have recently spent time in the many pools or at the many beaches here in California.
I have found that the difficult task in diagnosing otitis externa is determining the source of the otorrhea, whether a perforated tympanic membrane or the canal itself. Recognizing the thick discharge and the erythematous walls of the canal is fairly simple. Trying to see beyond the mass of Pseudomonas aeruginosa, Staphylococcus aureus, gram-negative rods, or saprophytic fungi to the tympanic membrane is nearly impossible. As a result, treatment can sometimes consist of both neomycin, polymyxin, and hydrocortisone otic drops and oral antibiotics for possible acute otitis media.
AURAL FOREIGN BODIES
"I put the bead in there to see if it would fit." This answer may seem obvious to a 4 year old, but when faced with attempting to remove a foreign body from the external auditory canal, most frenzied residents still mutter, "Why did you put it in there?"
In our urgent care clinics and emergency rooms, our residents have encountered children with bits of food, jewelry, rocks, paper, insects, and a variety of other objects in their ears. Treating these children effectively and with the least psychological and physical trauma often requires drawing on everything in our beings that led us to pediatrics.
Initially, I thought I could try to remove just about anything. I have learned better. Do not attempt to remove a dry bean with irrigation. Insects can be smothered in microscope immersion oil. Always ask for help in "holding" your patient. There is always an otorhinolaryngology physician on-call.
From a pediatric resident's perspective, a child's ears are one of our staked out claims in the land of medicine. Learning to identify and manage the conditions that affect these ears and our patients makes up a significant portion of our educational experience during and, no doubt, after residency. A child "pulling at her ear" is an opportunity for a pediatric resident to practice the art and the science of medicine.
Ansley J, Cunningham M. Treatment of aural foreign bodies in children. Pediatrics. 1998;101:638-641.
Bluestone C, Blumer J, Paradise J, Klein J. Proceedings of a symposium: otitis media: management in the era of resistant bacteria. Pediatr Infect Dis J. 1998;17:1065-1101.
Zitelli B, Davis H. Atlas of Pediatric Physical Diagnosis, 3rd ed. St. Louis, MO: Mosby; 1997:683-728.