Diagnosis and Management
Diagnosis
This patient has acute otitis media (AOM) with tympanic membrane perforation, not otitis externa, despite the positive tug test. The bulging tympanic membrane with purulent green discharge and perforation are pathognomonic for AOM 1, 2. The positive tug test is a red herring in this case—while typically associated with otitis externa, the otoscopic findings definitively establish the diagnosis as AOM with perforation 3, 4.
Key Diagnostic Features Present:
- Acute onset of otalgia and fever 1
- Middle ear effusion confirmed by bulging tympanic membrane and otorrhea through perforation 1, 2
- Signs of middle ear inflammation evidenced by the bulging membrane and purulent discharge 1
Critical Distinction from Otitis Externa:
In otitis externa, the tympanic membrane maintains normal mobility and typically shows a normal peaked curve on tympanometry 5. The primary pathology is in the ear canal itself (edema, erythema), not the tympanic membrane 5. This patient's bulging tympanic membrane with perforation indicates middle ear disease, not external canal disease 1, 2, 3.
Management
Immediate Treatment
Prescribe topical ofloxacin otic solution 10 drops (0.5 mL) twice daily for 14 days 6. This is the FDA-approved treatment for chronic suppurative otitis media with perforated tympanic membranes in patients 12 years and older 6. The patient should lie with the affected ear upward, instill the drops, pump the tragus 4 times to facilitate middle ear penetration, and maintain position for 5 minutes 6.
Pain Management
Address pain control immediately with analgesics 1. Pain management during the first 24 hours is essential regardless of antibiotic use 1. Options include acetaminophen or ibuprofen based on patient preference and contraindications 1.
Systemic Antibiotics Consideration
While topical therapy is first-line for perforated AOM 6, consider adding oral amoxicillin 500-875 mg twice daily if systemic symptoms (fever, malaise) are prominent 1, 4. The presence of fever and feeling "feverish" suggests systemic involvement that may benefit from oral antibiotics 1, 4.
Follow-Up
Schedule follow-up in 48-72 hours to assess clinical response 1. If symptoms worsen or new symptoms develop (posterior auricular swelling, neurological symptoms, severe headache), imaging may be necessary to evaluate for complications such as mastoiditis or intracranial extension 1.
Important Caveats
- Do not use ototoxic aminoglycosides (gentamicin, neomycin) in the setting of tympanic membrane perforation, as they can cause permanent hearing loss 6
- Ofloxacin is safe for perforated membranes and achieves high concentrations in otorrhea (389-2,850 mcg/g) 6
- The perforation may heal spontaneously after infection resolution, but persistent perforation beyond 2-3 months requires ENT referral 3
- Common bacterial pathogens in AOM include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 4, 7