What is the treatment for an adult with 2 days of ear pain, presenting with a bilateral (BL) tympanic membrane (tm) that is translucent with an air-fluid level and visible bubbles?

From the Guidelines

For an adult with 2 days of ear pain and bilateral tympanic membranes showing translucency with air-fluid levels and visible bubbles, I recommend treating for acute otitis media with antibiotics. The presence of air-fluid levels with bubbles suggests acute inflammation, which is consistent with the diagnosis of acute otitis media as defined by the American Academy of Pediatrics and the American Academy of Family Physicians 1. The first-line treatment is amoxicillin 500mg three times daily for 5-7 days, as it is effective in reducing the duration and severity of symptoms 1. If the patient has penicillin allergy, azithromycin 500mg on day 1 followed by 250mg daily for 4 more days is an appropriate alternative. For pain management, I recommend ibuprofen 400-600mg every 6 hours or acetaminophen 650mg every 6 hours as needed. Key points to consider in management include:

• The patient should avoid getting water in the ears until symptoms resolve
• If symptoms don't improve within 48-72 hours of starting antibiotics, the patient should follow up for reassessment as they may need a different antibiotic if the infection is resistant to the initial treatment
• The diagnosis of acute otitis media is based on the presence of middle-ear effusion and signs or symptoms of middle-ear inflammation, which are indicated by the air-fluid level and visible bubbles behind the tympanic membrane 1. Recent studies have shown that antibiotics are beneficial in reducing the duration and severity of symptoms in acute otitis media, particularly in children younger than 2 years with bilateral AOM and in children with otorrhea 1. Although the current patient is an adult, the principles of management remain similar, with a focus on relieving symptoms and preventing complications. Overall, the use of antibiotics in this case is warranted due to the presence of acute inflammation and the potential for complications if left untreated 1.

From the FDA Drug Label

Adults and Pediatric Patients Upper Respiratory Tract Infections of the Ear, Nose, and Throat Infections of the Genitourinary Tract Infections of the Skin and Skin Structure Infections of the Lower Respiratory Tract

Table 1 Ear/Nose/Throat Mild/ Moderate 500 mg every 12 hours or 250 mg every 8 hours Severe 875 mg every 12 hours or 500 mg every 8 hours

The recommended dosage of amoxicillin for an adult with ear pain is 500 mg every 12 hours or 250 mg every 8 hours for mild to moderate infections, and 875 mg every 12 hours or 500 mg every 8 hours for severe infections 2.

• The presence of an air-fluid level and visible bubbles in the ear suggests a possible bacterial infection, which may require antibiotic treatment.
• Amoxicillin is indicated for the treatment of upper respiratory tract infections, including those of the ear, nose, and throat.
• The dosage should be continued for a minimum of 48 to 72 hours beyond the time that the patient becomes asymptomatic, or evidence of bacterial eradication has been obtained 2.

From the Research

Diagnosis and Treatment of Ear Pain

• The patient presents with 2 days of ear pain, and the examination reveals a translucent tympanic membrane (TM) with an air-fluid level and visible bubbles, indicating the presence of middle ear effusion 3.
• The diagnosis of acute otitis media (AOM) is made based on the presence of middle ear effusion, physical evidence of middle ear inflammation, and symptoms such as pain, irritability, or fever 3.
• The management of AOM should begin with adequate analgesia, and antibiotic therapy can be considered in patients who are not allergic to penicillin, with high-dose amoxicillin (80 to 90 mg per kg per day) being the antibiotic of choice 3.

Causes of Ear Pain

• Ear pain can be primary, originating from the ear, or secondary, originating from outside the ear 4.
• Primary otalgia is more common in children, while secondary otalgia is more common in adults 4.
• The most common causes of primary otalgia include otitis media and otitis externa, while the most common causes of secondary otalgia include temporomandibular joint syndrome and dental infections 4.

Treatment of Otitis Media with Effusion

• Otitis media with effusion (OME) is defined as the presence of fluid in the middle ear without signs or symptoms of acute ear infection 5, 6.
• The treatment of OME is generally focused on watchful waiting, with the majority of cases resolving spontaneously within 3 months 6.
• Antibiotics, decongestants, or nasal steroids are not recommended for the treatment of OME, as they do not hasten the clearance of middle ear fluid and may contribute to antimicrobial resistance 5, 6.
• Tympanostomy tubes may be considered in patients with chronic OME or those who are at risk for speech, language, or learning problems due to middle ear effusion 6.