What is the diagnosis and management for a 3-year-old female, weighing 12.5kg, presenting with bilateral painful ears, fever, and pus discharge, but no bleeding, with seemingly intact eardrums and a history of regular ear cleaning?

Diagnosis

This is acute otitis media (AOM) with spontaneous tympanic membrane perforation, presenting as bilateral purulent otorrhea. The combination of acute onset bilateral ear pain, fever, and subsequent purulent discharge with intact-appearing eardrums on examination is diagnostic of AOM with perforation that has already begun to heal 1.

Key Diagnostic Features

• Acute onset (yesterday) with fever and bilateral ear pain followed by purulent discharge confirms AOM rather than chronic suppurative otitis media 1
• Purulent otorrhea without bleeding indicates bacterial infection with tympanic membrane perforation that allowed middle ear fluid to drain 1, 2
• Seemingly intact eardrums on current examination suggest the perforation has already begun healing, which commonly occurs after drainage relieves pressure 1
• Age 3 years places this child in the highest risk group for AOM (peak incidence 1-4 years) 3

Important Caveat About Weekly Ear Cleaning

The history of weekly ear cleaning by a relative is concerning and may represent a risk factor for recurrent infections or could indicate chronic otitis externa being mistaken for AOM 4. However, given the acute presentation with fever and bilateral involvement, this is clearly AOM with perforation 1.

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Management

Immediate systemic antibiotic therapy is mandatory for this child. Children with perforated tympanic membranes and purulent discharge require antibiotics regardless of age or symptom severity 4, 5.

Antibiotic Selection and Dosing

First-line: High-dose amoxicillin 80-90 mg/kg/day in 2 divided doses

• For this 12.5 kg child: 1000-1125 mg total daily dose, given as 500-562.5 mg twice daily 4, 2, 6
• Amoxicillin remains the clear drug of choice due to effectiveness against S. pneumoniae, H. influenzae, and M. catarrhalis, plus excellent safety profile, low cost, and narrow spectrum 4, 7

Alternative if amoxicillin used in past 30 days or treatment failure:

• Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin component (6.4 mg/kg/day clavulanate) in 2 divided doses 4, 7
• For this child: approximately 1125 mg amoxicillin component daily

Penicillin allergy alternatives:

• Cefdinir 14 mg/kg/day (175 mg daily for this child) 4, 2
• Cefuroxime 30 mg/kg/day (375 mg daily) 4
• Ceftriaxone 50 mg/kg IM daily for 1-3 days if oral therapy fails 4

Treatment Duration

10 days of antibiotic therapy is required because this child is under 6 years of age 4, 7. The 7-day course is only appropriate for children 2-5 years with mild-to-moderate AOM without perforation 4.

Pain Management

Immediate analgesia is essential regardless of antibiotic therapy:

• Acetaminophen 15 mg/kg/dose every 4-6 hours (approximately 187 mg per dose for this child) 4, 2
• Ibuprofen 10 mg/kg/dose every 6-8 hours (approximately 125 mg per dose) 4, 2
• Pain control must be addressed immediately as it significantly impacts quality of life 1, 4

Critical Management Points

Do NOT use topical antibiotic drops - these are contraindicated in acute suppurative otitis media with perforation unless specifically designed for middle ear use (quinolone ototopical preparations) 1, 4. Aminoglycoside-containing drops are ototoxic with non-intact tympanic membranes 1.

Stop the weekly ear cleaning immediately - this practice may be traumatizing the ear canal and potentially introducing infection 4. Counsel the family that routine ear cleaning is unnecessary and potentially harmful 4.

Follow-up and Reassessment

• Reassess at 48-72 hours if symptoms worsen or fail to improve 4, 7
• If treatment fails, switch to amoxicillin-clavulanate or consider ceftriaxone 4, 7
• Expect middle ear effusion to persist for weeks to months after successful treatment (60-70% at 2 weeks, 40% at 1 month) - this is otitis media with effusion (OME) and does not require additional antibiotics 4

Prevention Counseling

Address modifiable risk factors to prevent recurrence 4:

• Ensure pneumococcal (PCV-13) and annual influenza vaccination are up to date 4, 2
• Minimize tobacco smoke exposure 4, 3
• Reduce pacifier use if applicable 4
• Consider daycare attendance patterns if relevant 3

When to Consider Specialist Referral

Refer to ENT if:

• Three or more episodes within 6 months or four episodes within 1 year 4, 2
• Multiple treatment failures requiring tympanocentesis for culture 4
• Persistent bilateral OME beyond 3 months with hearing loss 4
• Development of complications (mastoiditis, though rare) 1