What is the appropriate management for an 11-year-old patient presenting with a possible ear infection in the left ear, a history of inserting a cotton swab (Q-tip) into the ear, and elevated Patient Health Questionnaire (PHQ) and Generalized Anxiety Disorder 7 (GAD-7) scores, who is willing to start medication and has a history of suicidal ideation (SI) but none in the past two months?

From the Guidelines

The patient should be managed with gentle irrigation of the ear and consideration of antibiotic treatment, while also addressing anxiety and depression with fluoxetine and cognitive behavioral therapy, with close monitoring for suicidal ideation and side effects. For the ear concern, gentle irrigation with body-temperature water using a bulb syringe to remove any cotton debris is recommended, as inserting objects into the ear canal can exacerbate cerumen impaction and lead to injuries, as noted in the study by 1. If this is unsuccessful or if signs of infection are present (pain, redness, discharge), prescribing amoxicillin 40mg/kg/day divided twice daily for 7-10 days is a suitable option. It is essential to avoid ear drops until confirming no tympanic membrane perforation. For her anxiety and depression, starting fluoxetine (Prozac) at 10mg daily for 2 weeks, then increasing to 20mg daily if well-tolerated, is recommended, as this SSRI has FDA approval for children with depression and anxiety, and the study by 1 provides guidance on its use. Close follow-up is essential, with a return visit in 2 weeks to assess medication response and side effects. Monitoring for increased suicidal ideation, especially during the first month of treatment, is crucial, as noted in the study by 1. Concurrent cognitive behavioral therapy is also recommended, as combination treatment shows better outcomes than medication alone, and providing education about potential side effects, including nausea, headache, sleep changes, and the delayed therapeutic effect (4-6 weeks for full benefit), is necessary. Key considerations in managing this patient include:

• Avoiding further insertion of objects into the ear canal to prevent exacerbating cerumen impaction or causing injuries, as highlighted in the study by 1
• Monitoring for signs of infection and adjusting treatment accordingly
• Close follow-up to assess medication response and side effects, particularly suicidal ideation, as emphasized in the study by 1
• Providing education on potential side effects and the importance of concurrent cognitive behavioral therapy, as noted in the study by 1
• Considering the patient's history of suicidal ideation and the need for careful monitoring and support, as discussed in the study by 1

From the FDA Drug Label

Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs Pooled analyses of short–term placebo–controlled trials of antidepressant drugs (SSRIs and others) showed that these drugs increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (ages 18–24) with major depressive disorder (MDD) and other psychiatric disorders All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases

The patient is an 11-year-old with a history of suicidal ideation, elevated PHQ and GAD-7 scores, and is willing to start medication. Given the patient's history of suicidal ideation and the increased risk of suicidality in pediatric patients taking antidepressants, the patient should be monitored closely for clinical worsening, suicidality, and unusual changes in behavior.

• The patient's history of inserting a cotton swab into the ear and possible ear infection is not directly related to the management of their psychiatric condition.
• The patient's elevated PHQ and GAD-7 scores indicate a need for close monitoring of their mental health.
• Fluoxetine is approved in the pediatric population only for major depressive disorder and obsessive compulsive disorder 2. It is essential to weigh the benefits and risks of treatment with fluoxetine in this patient, considering their history of suicidal ideation and elevated anxiety scores. Close monitoring and regular follow-up are crucial to ensure the patient's safety while on medication.

From the Research

Ear Infection Management

• The patient's history of inserting a cotton swab (Q-tip) into the ear may have contributed to the ear infection, as noted in the context of ear infections being a common presentation to acute care environments 3.
• For a child aged 2 months through 12 years with otitis media with effusion (OME), the American Academy of Otolaryngology-Head and Neck Surgery Foundation recommends watchful waiting for 3 months from the date of effusion onset or diagnosis, and against using intranasal or systemic steroids, systemic antibiotics, antihistamines, or decongestants for treating OME 4.

Anxiety and Suicidal Ideation Considerations

• The patient's elevated Patient Health Questionnaire (PHQ) and Generalized Anxiety Disorder 7 (GAD-7) scores, as well as history of suicidal ideation, should be taken into account when managing their care, although there is no direct evidence in the provided studies to guide this aspect of their treatment.
• The patient's willingness to start medication should be considered in the context of their overall health and well-being.

Antibiotic Treatment for Acute Otitis Media

• Antibiotics may be considered for the treatment of acute otitis media (AOM), but the benefits must be weighed against the possible harms, including adverse events such as vomiting, diarrhea, or rash 5.
• A comparison of amoxicillin and azithromycin for the prevention of recurrent AOM found both treatments to be effective, with similar incidence of adverse effects 6.
• An update on the consensus document for the treatment of AOM and sinusitis recommends high-dose amoxicillin or amoxicillin-clavulanic acid as first-line antibiotic treatment, with short-course regimens lasting 5-7 days for patients with uncomplicated disease 7.