Ear, nose and throat for PLAB 1

A 4 year old girl has had left ear pain and fever for two days after a cold. She is eating and drinking normally and is alert and playful. Her temperature is 37.9°C. Otoscopy shows a red, bulging left tympanic membrane with no discharge. The right ear is normal. What is the SINGLE most likely diagnosis?

1. Otitis externa Pain on moving the tragus or pinna with a swollen, debris-filled canal and a normal drum where it can be seen. Two days of symptoms in a well child points elsewhere.
2. Perforated TM Common, usually painless once it happens because it relieves the pressure, and it heals within weeks. Parents should be warned they may see discharge, and two days of symptoms in a well child here points elsewhere.
3. Otitis media correct Correct. A red, bulging tympanic membrane with ear pain and fever after a coryzal illness in a preschool child. Bulging is the finding that matters, a merely pink drum in a crying child is not otitis media.
4. Foreign body - ear Sudden unilateral pain or discharge with a visible object, usually in a young child. Two days of symptoms in a well child shows no foreign body.
5. Otitis media with effusion Painless hearing loss with a dull, retracted, immobile drum and no acute inflammation. Two days of symptoms in a well child is acute instead.

The point: Most acute otitis media is viral and self-limiting: analgesia and a no-antibiotic or back-up prescribing strategy. Give antibiotics immediately if systemically unwell, at high risk of complications, symptoms lasting 4 days or more, otorrhoea, or under 2 with bilateral disease. Amoxicillin for 5 to 7 days. A tender, boggy, pushed-forward pinna with mastoid swelling is mastoiditis and needs admission.

Source: NICE NG91 — Otitis media (acute): antimicrobial prescribing NICE · tier 1, national regulator or guidance

A 4 year old girl has had left ear pain and fever for two days after a cold. She is eating and drinking normally and is alert and playful. Her temperature is 37.9°C. Otoscopy shows a red, bulging left tympanic membrane with no discharge. The right ear is normal. What is the SINGLE most appropriate initial investigation?

1. CT of the temporal bones For suspected mastoiditis or intracranial complications. Two days of symptoms in a well child warrants it.
2. Otoscopy correct Correct. The examination that makes the diagnosis and separates it from otitis externa and from referred pain with a normal ear. No further test is needed in an uncomplicated case.
3. Tympanometry Assesses middle ear effusion and drum mobility, used in glue ear rather than acute infection. Two days of symptoms in a well child makes it the wrong setting.
4. Pure tone audiometry For persistent hearing loss after the acute episode settles. Two days of symptoms in a well child makes it a follow-up test.
5. No investigation; this is a clinical diagnosis Otoscopy plus the history is enough in an uncomplicated case. Two days of symptoms in a well child makes it straightforward.

The point: Most acute otitis media is viral and self-limiting: analgesia and a no-antibiotic or back-up prescribing strategy. Give antibiotics immediately if systemically unwell, at high risk of complications, symptoms lasting 4 days or more, otorrhoea, or under 2 with bilateral disease. Amoxicillin for 5 to 7 days. A tender, boggy, pushed-forward pinna with mastoid swelling is mastoiditis and needs admission.

Source: NICE NG91 — Otitis media (acute): antimicrobial prescribing NICE · tier 1, national regulator or guidance

A 4 year old girl has had left ear pain and fever for two days after a cold. She is eating and drinking normally and is alert and playful. Her temperature is 37.9°C. Otoscopy shows a red, bulging left tympanic membrane with no discharge. The right ear is normal. What is the SINGLE most appropriate immediate management?

1. Admit for intravenous antibiotics and ENT review For mastoiditis or suspected intracranial complication. Two days of symptoms in a well child demands it.
2. Clarithromycin The alternative where there is penicillin allergy. Two days of symptoms in a well child makes allergy the deciding factor.
3. Analgesia and a back-up antibiotic prescription correct Correct. She is systemically well, unilateral, over 2, symptoms under 4 days and no otorrhoea, so she does not meet any immediate-antibiotic criterion. Most cases resolve within three days regardless of treatment. Regular paracetamol or ibuprofen, and a back-up prescription to use only if she is no better in three days or gets worse.
4. Immediate amoxicillin for 5 to 7 days For systemic illness, high risk of complications, symptoms 4 days or more, otorrhoea, or a child under 2 with bilateral disease. Two days of symptoms in a well child meets a criterion.
5. Topical antibiotic and aural toilet The treatment for otitis externa, acting where the infection is. Two days of symptoms in a well child points to a different diagnosis.

The point: Most acute otitis media is viral and self-limiting: analgesia and a no-antibiotic or back-up prescribing strategy. Give antibiotics immediately if systemically unwell, at high risk of complications, symptoms lasting 4 days or more, otorrhoea, or under 2 with bilateral disease. Amoxicillin for 5 to 7 days. A tender, boggy, pushed-forward pinna with mastoid swelling is mastoiditis and needs admission.

Source: NICE NG91 — Otitis media (acute): antimicrobial prescribing NICE · tier 1, national regulator or guidance