Diagnosis and Management of Acute Otitis Media and Acute Otitis Externa for the Urgent Care Clinician (Pharmacology CME and Infectious Disease CME)

Table of Contents

 

About This Issue

Acute otitis media (AOM) and acute otitis externa (AOE) are common reasons for seeking care in the urgent care setting. A thorough examination of the patient, including otoscopic examination, is crucial for appropriate management. Most patients with AOM or AOE will be discharged from the urgent care without complications; however, certain circumstances and populations may need more advanced care. In this issue, you will learn:

How the presentation, physical examination, and differential diagnosis are used to guide treatment

When to use the “watch and wait” approach in treating acute otitis media with antibiotics in the pediatric population

Which complications warrant referral to more advanced care

CODING & CHARTING: Coding for patients who present with ear pain (AOM or AOE) is determined by specific presentation and management complexity. Learn more in our monthly coding column.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Anatomy of the Ear
6. Acute Otitis Media
   1. Definition
   2. Epidemiology and Pathophysiology
   3. Complications
7. Acute Otitis Externa
   1. Definition
   2. Epidemiology and Pathophysiology
   3. Complications
8. Differential Diagnosis of Otalgia
9. Urgent Care Evaluation
   1. Physical Examination
      1. General
      2. External Ear
   2. Otoscopic Examination
      1. Acute Otitis Media
      2. Acute Otitis Externa
      3. Pneumatic Otoscopy
10. Diagnostic Studies
    1. Laboratory Studies
    2. Computed Tomography and Magnetic Resonance Imaging
       1. Mastoiditis and Malignant Otitis Externa
11. Treatment and Disposition
    1. Acute Otitis Media
       1. Antibiotics
       2. Penicillin Allergy
       3. Disposition
    2. Acute Otitis Externa
       1. Topical Therapy
       2. Disposition
12. Additional Therapies for Acute Otitis Media and Acute Otitis Externa
    1. Aural Toilet
    2. Pain Management
    3. Adjunctive Therapies
13. Considerations for Referral or Hospital Evaluation
    1. Indications for Otolaryngology Referral
    2. Indications for Hospital Evaluation
14. Special Populations
15. Summary
16. Controversies/Cutting Edge
    1. Technology to Assist With Ear Examination
    2. Pathogen-directed Therapy
    3. “Watch and Wait” Approach for Acute Otitis Media in Pediatrics
17. Prevention
    1. Acute Otitis Media
    2. Acute Otitis Externa
18. Risk Management Pitfalls in the Management of Acute Otitis Media/Acute Otitis Externa in the Urgent Care Setting
19. Time- and Cost-Effective Strategies
20. Critical Appraisal of the Literature
21. 5 Things That Will Change Your Practice
22. Case Conclusions
23. KidBits: Acute Otitis Media and Acute Otitis Externa in Pediatric Patients
    1. Risk Factors
    2. Clinical Presentation and Diagnosis
       1. Acute Otitis Media
       2. Acute Otitis Externa
    3. Treatment
       1. Acute Otitis Media
       2. Acute Otitis Externa
    4. Clinical Pathways
       1. KidBits Clinical Pathway for the Evaluation and Management of Acute Otitis Media in Pediatric Patients Aged <6 Months
       2. KidBits Clinical Pathway for the Evaluation and Management of Acute Otitis Media in Pediatric Patients Aged ≥6 Months
    5. References
24. Coding & Charting: What You Need to Know
    1. Number and Complexity of Problems Addressed
    2. Amount and/or Complexity of Data to be Reviewed and Analyzed
    3. Risk of Complications and/or Morbidity or Mortality of Patient Management
25. Coding Challenge: Ear Pain in Urgent Care
26. Clinical Pathways
    1. Clinical Pathway for the Management of Acute Otitis Media in Adult Patients in Urgent Care
    2. Clinical Pathway for the Management of Acute Otitis Externa in Urgent Care
27. References

Abstract

Acute otalgia is a common reason why patients, particularly those in the pediatric population, seek care in the urgent care setting. Although many patients who present with acute otalgia will have acute otitis media (AOM) or acute otitis externa (AOE), the differential diagnosis is complicated by trauma, cerumen impaction, tonsillitis, foreign bodies, or other infections. While most cases of AOM or AOE can be managed in urgent care, more severe disease processes will require referral to otolaryngology and/or the emergency department. This review provides evidence-based recommendations for the evaluation and management of patients with acute otalgia, with a focus on the diagnosis and treatment of AOM and AOE. Current guidelines on antibiotic treatment for AOM and AOE are discussed, including the "watch and wait" approach for AOM in the pediatric population.

Case Presentations

A 7-year-old boy with his parents presents with right ear pain and fever for 2 days...

• You see a bulging, erythematous tympanic membrane on examination.
• You choose to treat for acute otitis media, but Mom tells you this is the patient’s second ear infection in the past month.
• What is the most appropriate course of treatment?

A 17-year-old adolescent girl presents with severe right ear pain for 5 days...

• You see a bulging, erythematous tympanic membrane with erythema and tenderness to the patient’s mastoid process.
• She also has a fever of 102°F.
• What is your next step in management?

A 60-year-old diabetic man presents with left ear pain and drainage for the past 4 days...

• You see a very inflamed, erythematous external ear with otorrhea.
• The patient tells you he was recently on some “antibiotic drops” but they are not helping.
• You wonder if the patient should be transferred to the hospital for further management and possible specialist consultation…

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. * Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999. (Evidence-based clinical practice guideline) DOI: 10.1542/peds.2012-3488

4. * Schilder AG, Chonmaitree T, Cripps AW, et al. Otitis media. Nat Rev Dis Primers. 2016;2(1):16063. (Review) DOI: 10.1038/nrdp.2016.63

8. * Kaur R, Morris M, Pichichero ME. Epidemiology of acute otitis media in the postpneumococcal conjugate vaccine era. Pediatrics. 2017;140(3):e20170181. (Prospective, longitudinal cohort study; 615 patients) DOI: 10.1542/peds.2017-0181

16. * Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014;150(1 Suppl):S1-S24. (Evidence-based clinical practice guideline) DOI: 10.1177/0194599813517083

45. * Venekamp RP, Sanders SL, Glasziou PP, et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2023;11(11):CD000219. (Systematic review; 13 randomized controlled trials, 3401 patients) DOI: 10.1002/14651858.CD000219.pub5

Subscribe to get the full list of 55 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: acute otitis media, acute otitis externa, otitis media, acute otalgia, mastoiditis, malignant otitis externa, ear infection, tympanic membrane, chronic suppurative otitis media, otitis media with effusion, otoscopic examination, cerumen, antibiotics and acute otitis media, aural toilet, topical antibiotics, tympanostomy tubes