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Lesson 5 of8
In Progress

Diagnosis

Jimmy October 26, 2021

There is no array of specific symptoms or any particular scoring system that ascertain pediatric OM. An understanding of the associated risk factors and the clinical presentation as described are preludes to decide for further examination. When these are firmly assessed, an examination of the tympanic membrane is then done to make an accurate diagnosis.

  1. An Otoscopic evaluation is done to examine the characteristics of the tympanic membrane and it is usually sufficient to confirm OM diagnosis. Blocking cerumen may be removed via curette, gentle suction, or irrigation for better visualization. For pediatric patients, consider the placement of 3% hydrogen peroxide or emulsifying drops, followed by gentle irrigation if curettage is unsuccessful.

Evaluate for the following characteristics of the tympanic membrane to decide whether it is within normal parameters or manifests OM:

TM Evaluation on:Possible Evaluations:Normal Findings:OM Findings:
ContourNormal, retracted, full, bulgingNormalBulging, suggesting bacterial pathogen
ColorGray, yellow, pink, white, redPearly grayIntense erythema, almost hemorrhagic
TranslucencyTranslucent, semiopaque, opaqueGround-glass appearance, translucentOpaque or cloudy
MobilityNormal, increased, decreased, absentNormal, moves inward with pneumatic positive pressure, outward with negative pressureDecreased or absent
Visualization of landmarks(pars flaccida, malleolus, light relflex below the umbo)Visibile or not visibleVisibleNot visible due to opacification and middle ear effusion

Note that in neonates, the TM is in a highly oblique position and normally appears thickened and opaque in the first few weeks of life. A comparison examination of the other ear may help in confirming a suspected infection. If the tube is patent, erythema and discharge indicate the infection. If the tube is not patent, typical erythema, bulging of the TM, and immobility indicate pediatric OM.


2. Tympanometry for objective measure of Middle Ear Function and Middle Ear Effusion

  • OM should not be diagnosed in the absence of middle ear effusion
  • Measures transfer of acoustic energy as a function of ear canal pressure
  • Generates a graph showing how energy admitted to ear canal is reflected back to the internal microphone canal while canal pressure varies from negative to positive
  • Flat or nearly flat tracing is indicative of impaired TM vibration due to middle ear fluid which is also a manifestation of OM

Other Diagnostic Testings:

  1. Tympanocentesis
  • Consider for OM with repeated treatment failure
  • Send middle ear fluid specimen for Gram stain, culture, and sensitivity and results will identify presence of causative agents that suggests OM
  1. Nasopharyngeal Culture
    • Considered for OM with repeated treatment failure if tympanocentesis is not feasible

When all have been assessed and a positive diagnosis is confirmed, diagnose with mild pediatric OM those with mild otalgia and a temperature of <39◦C (102.2◦F) and diagnose with severe pediatric OM those with moderate-to-severe otalgia or a fever that is ≥39◦C (102.2◦F)


Causative organisms

Most Common:

  • Streptococcus pneumoniae – predominant cause of pediatric OM – Mean frequency: 27.8%
  • Nontypeable Haemophilus influenza – likely to cause conjunctivitis-associated OM – Mean frequency: 23.1%
  • Moraxella (Branhamella) catarrhalis – Mean frequency: 7%

Less Common:

  • Streptococcus pyogenes – can be necrotizing
  • Mycoplasma spp.

Less Likely:

  • Mycobacterium tuberculosis – primarily in children
  • Chlamydia trachomatis – most commonly seen in children < 6 months