What is the diagnosis and treatment for a 27-year-old female (YOF) with fever, left ear pain radiating to the jaw, chills, nausea, and congestion, and a history of multiple ear infections and tympanostomy tubes?

Acute Otitis Media (AOM) - Diagnosis and Treatment

Diagnosis

This patient has acute otitis media (AOM), diagnosed by the combination of acute symptoms (fever, ear pain, chills, nausea) and her history of recurrent ear infections. 1

Key Diagnostic Criteria

• AOM requires three elements: presence of middle ear effusion (MEE), signs of middle ear inflammation, and acute onset of symptoms 1
• Specific findings to confirm on exam: bulging tympanic membrane (mild, moderate, or severe), decreased or absent tympanic membrane mobility on pneumatic otoscopy, and acute symptoms including ear pain, fever, and systemic illness 1
• Pain radiating to the jaw is consistent with referred pain from middle ear inflammation, a common presentation of AOM 1
• History of recurrent infections and tubes places her at higher risk for ongoing middle ear disease 1

Critical Examination Points

• Assess tympanic membrane for bulging (most diagnostic for AOM), color changes (erythema, opacity), and position 1
• Perform pneumatic otoscopy to evaluate tympanic membrane mobility - absent or decreased movement indicates MEE 1
• Check if previous tympanostomy tubes are still in place or if perforation exists from prior tubes 1

Treatment Approach

High-dose amoxicillin (80-90 mg/kg/day in two divided doses) is first-line antibiotic therapy for adults with AOM, unless she has taken amoxicillin in the past 30 days or has penicillin allergy. 1, 2

Antibiotic Selection Algorithm

• First-line: Amoxicillin 80-90 mg/kg/day divided twice daily for 7-10 days 1
• If amoxicillin used within past 30 days: Amoxicillin-clavulanate (high-dose amoxicillin component: 90 mg/kg/day) 1, 2
• If penicillin allergy: Cefdinir or azithromycin (though azithromycin shows equivalent efficacy to amoxicillin-clavulanate at 12-14 days but is less preferred) 1, 3, 2
• Duration: 7-10 days is standard; amoxicillin-clavulanate showed superior cure rates at 10 days compared to shorter courses 1

Pain Management - Critical First Step

Analgesics must be prescribed regardless of antibiotic use and should be started immediately, as antibiotics do not provide symptomatic relief in the first 24 hours. 1

• Pain relief is the primary concern in the first 24-48 hours 1
• Use acetaminophen or ibuprofen as needed for otalgia 1
• Continue analgesics as long as pain persists, even if antibiotics are prescribed 1

Important Clinical Considerations

Watchful Waiting Not Appropriate Here

• Observation without antibiotics is only appropriate for: unilateral AOM in children 6-23 months with mild symptoms (otalgia <48 hours, temperature <39°C) 1
• This patient requires antibiotics because she has systemic symptoms (fever, chills, nausea) indicating more severe disease 1

Common Pitfalls to Avoid

• Do not confuse AOM with otitis media with effusion (OME): OME lacks acute infection signs (fever, acute pain) and presents primarily with hearing loss 4
• Do not use antibiotics for OME: they lack long-term efficacy and are not indicated 4
• Do not prescribe antihistamines or decongestants: these have no proven benefit in AOM or OME 4

Follow-Up Considerations

• Recheck in 48-72 hours if symptoms worsen or fail to improve 1
• Persistent effusion after treatment is common: 60-70% have MEE at 2 weeks, 40% at 1 month, 10-25% at 3 months after successful AOM treatment 4
• If MEE persists beyond 3 months without symptoms, this becomes OME and requires different management (watchful waiting, possible hearing assessment) 4

Red Flags Requiring Urgent Referral

• Signs of mastoiditis (postauricular swelling, erythema, tenderness) 1
• Severe systemic toxicity or suspected intracranial complications 1
• Facial nerve paralysis 1