Acute otitis media — branching viva

Opening

Examiner: A 16-month-old is brought to you with two days of a cold, ear tugging and a fever. Pneumatic otoscopy shows a bulging, opaque, poorly mobile right tympanic membrane; the left is normal. How do you make the diagnosis and what is your first step? ^[1]

Candidate: This is acute otitis media of the right ear, confirmed by a bulging tympanic membrane that has lost its mobility on pneumatic otoscopy — the key finding, supported by the acute otalgia and fever and the preceding viral prodrome. My first step in every child with AOM is analgesia: paracetamol 15 mg/kg orally every four to six hours, or ibuprofen 5 to 10 mg/kg every six to eight hours, because the pain is often severe. The antibiotic decision is a separate step that depends on age, laterality and severity. ^{[1] [2]}

Branch 1 — the antibiotic decision

Examiner: So will you give an antibiotic? ^[1]

Candidate: I would apply the age-and-laterality matrix. He is 6 to 23 months with unilateral non-severe AOM — mild fever, still playing between bouts — and if the family is reliable I would offer watchful waiting with a safety-net rather than immediate antibiotics. The Cochrane evidence shows most children recover without antibiotics, with a modest average benefit concentrated in the youngest, the bilateral and those with otorrhoea. I would give a written safety-net to return at 48 to 72 hours if not improving, or at any time if worse. ^{[1] [3]}