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 Outer ear canal infection. Pain when the small flap in front of the ear or the outer ear is moved, with a swollen canal full of debris, and a normal eardrum where it can be seen. But two days of symptoms in a child who is otherwise well does not point to it.
2. Perforated TM A burst eardrum. Sudden relief of pain with discharge and a visible hole, often the natural way a middle ear infection settles. Here, two days of symptoms in a child who is otherwise well points elsewhere.
3. Otitis media correct Correct. A red, bulging eardrum with ear pain and fever after a cold, in a preschool child. Bulging is the finding that matters. A drum that is just a bit pink in a crying child is not a middle ear infection.
4. Foreign body - ear Something stuck in the ear. Sudden pain or discharge in one ear, with an object that can be seen, usually in a young child. That does not match two days of symptoms in a child who is otherwise well.
5. Otitis media with effusion Glue ear. Painless hearing loss with a dull, pulled-in eardrum that does not move, and no sign of an active infection. It does not fit two days of symptoms in a child who is otherwise well.

The point: Most acute middle ear infection (otitis media) is caused by a virus and gets better on its own: pain relief, and either no antibiotic or a back-up prescription to use only if needed. Give antibiotics straight away if the patient is generally unwell, at high risk of complications, has had symptoms for 4 days or more, has discharge from the ear (otorrhoea), or is under 2 years old with both ears affected. Amoxicillin for 5 to 7 days. A tender, soft, swollen ear that is pushed forward, with swelling over the bone behind it, is a mastoid bone infection (mastoiditis) and needs a hospital 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 Admitting the patient for antibiotics through a vein and a review by the ear, nose and throat team. Needed for a mastoid bone infection or a suspected brain complication. That does not match two days of symptoms in a child who is otherwise well.
2. Clarithromycin An antibiotic used instead of amoxicillin when the patient is allergic to penicillin. It does not fit two days of symptoms in a child who is otherwise well.
3. Analgesia and a back-up antibiotic prescription correct Correct. She is otherwise well, only one ear is affected, she is over 2, symptoms have lasted under 4 days and there is no ear discharge, so she does not meet any reason for antibiotics straight away. Most cases get better within three days whatever the treatment. Give regular paracetamol or ibuprofen, and a back-up antibiotic prescription to use only if she is no better in three days or gets worse.
4. Immediate amoxicillin for 5 to 7 days For a patient who is generally unwell, at high risk of complications, has had symptoms for 4 days or more, has ear discharge, or is a child under 2 with both ears affected. Here, two days of symptoms in a child who is otherwise well points elsewhere.
5. Topical antibiotic and aural toilet Antibiotic drops with careful cleaning of the ear canal. The treatment for an outer ear infection, working right where that infection is. But two days of symptoms in a child who is otherwise well does not point to it.

The point: Most acute middle ear infection (otitis media) is caused by a virus and gets better on its own: pain relief, and either no antibiotic or a back-up prescription to use only if needed. Give antibiotics straight away if the patient is generally unwell, at high risk of complications, has had symptoms for 4 days or more, has discharge from the ear (otorrhoea), or is under 2 years old with both ears affected. Amoxicillin for 5 to 7 days. A tender, soft, swollen ear that is pushed forward, with swelling over the bone behind it, is a mastoid bone infection (mastoiditis) and needs a hospital 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 definitive management?

1. Admit for intravenous antibiotics and ENT review Admitting the patient for antibiotics through a vein and a review by the ear, nose and throat team. Needed for a mastoid bone infection or a suspected brain complication. But two days of symptoms in a child who is otherwise well does not point to it.
2. Analgesia alone with safety-netting Pain relief on its own, with clear advice on when to come back. Right for a well child with symptoms under 4 days. It does not fit two days of symptoms in a child who is otherwise well.
3. Immediate amoxicillin for 5 to 7 days For a patient who is generally unwell, at high risk of complications, has had symptoms for 4 days or more, has ear discharge, or is a child under 2 with both ears affected. Here, two days of symptoms in a child who is otherwise well points elsewhere.
4. Clarithromycin An antibiotic used instead of amoxicillin when the patient is allergic to penicillin. That does not match two days of symptoms in a child who is otherwise well.
5. Grommet insertion correct Correct. Not now. Grommets are considered for fluid behind both eardrums with hearing loss lasting beyond three months, or for infections that keep coming back, neither of which applies to a first episode.

The point: Most acute middle ear infection (otitis media) is caused by a virus and gets better on its own: pain relief, and either no antibiotic or a back-up prescription to use only if needed. Give antibiotics straight away if the patient is generally unwell, at high risk of complications, has had symptoms for 4 days or more, has discharge from the ear (otorrhoea), or is under 2 years old with both ears affected. Amoxicillin for 5 to 7 days. A tender, soft, swollen ear that is pushed forward, with swelling over the bone behind it, is a mastoid bone infection (mastoiditis) and needs a hospital admission.

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