A 5‑year‑old boy with possible asthma, recently given oral prednisolone and inhaled salbutamol, now has right‑ear pain, fever, clear otorrhea, and decreased oral intake; what is the most likely diagnosis and what immediate management should be undertaken?

Acute Otitis Media with Otorrhea in a Child Recently Treated for Asthma Exacerbation

This is acute otitis media (AOM) with spontaneous tympanic membrane perforation, evidenced by the clear otorrhea, earache, and fever; immediate management should include analgesia (continue paracetamol), watchful waiting for 48-72 hours with safety-netting instructions, and continuation of the recently prescribed asthma medications.

Most Likely Diagnosis

This 5-year-old presents with classic features of acute otitis media with perforation:

• Earache that kept him awake indicates acute middle ear inflammation
• Clear discharge from the right ear represents spontaneous tympanic membrane perforation with drainage of middle ear fluid
• Fever and feeling warm support acute infection
• Recent viral illness (evidenced by wheezing requiring treatment) is the typical precipitant for AOM

The clear discharge specifically indicates the tympanic membrane has perforated, which often provides immediate pain relief but confirms the diagnosis of AOM.

Immediate Management Plan

Pain Control

• Continue paracetamol (Calpol) at appropriate weight-based dosing every 4-6 hours for pain and fever management
• Consider adding ibuprofen if paracetamol alone is insufficient (alternating dosing)

Antibiotic Decision

• Watchful waiting for 48-72 hours is appropriate for this child, as he does not have severe systemic illness

• Prescribe antibiotics immediately if:

  • Symptoms worsen or fail to improve within 48-72 hours
  • The child becomes systemically unwell
  • Bilateral AOM develops
  • The child is under 2 years with bilateral disease (not applicable here)

• If antibiotics become necessary: Amoxicillin 40-50 mg/kg/day divided three times daily for 5-7 days is first-line

Ear-Specific Care

• Keep the ear dry: No swimming, avoid getting water in the ear during bathing
• No ear drops or cotton buds in the ear canal
• The perforation will typically heal spontaneously within 2-3 weeks

Asthma Management Continuation

• Continue the prednisolone course as prescribed (typically 3-5 days total) 1
• Continue salbutamol as needed for any ongoing wheeze or breathlessness 1
• The recent prednisolone course does not treat the ear infection and should not be stopped prematurely

Hydration and Nutrition

• Continue pushing fluids as the parent is already doing
• Small, frequent meals are acceptable during acute illness
• No specific dietary restrictions needed

Safety-Netting Instructions

Return immediately or seek urgent care if:

• Increasing ear pain or swelling around/behind the ear (mastoiditis warning)
• High fever persisting beyond 48 hours
• The child becomes lethargic, confused, or has severe headache
• Breathing difficulty or severe wheeze develops
• Persistent vomiting or refusal of all fluids

Return within 48-72 hours if:

• No improvement in symptoms
• Discharge becomes purulent or foul-smelling
• New symptoms develop

Follow-Up Requirements

• Reassess in 48-72 hours if symptoms persist
• Follow-up in 4-6 weeks to confirm tympanic membrane healing and hearing is normal
• Asthma review within 1 week as per discharge planning after acute exacerbation 1

Critical Pitfalls to Avoid

• Do not stop the prednisolone course early: The child recently had an asthma exacerbation requiring systemic steroids, and the course must be completed 1
• Do not prescribe antibiotics reflexively: Spontaneous perforation with drainage often resolves without antibiotics in otherwise well children
• Do not assume the steroids will treat the ear infection: Prednisolone is for asthma inflammation, not bacterial otitis media
• Do not miss mastoiditis warning signs: Swelling or tenderness behind the ear, ear pushed forward, or severe systemic illness require immediate referral

Asthma Context Considerations

This child's possible asthma remains unconfirmed diagnostically 2, 3:

• At age 5, he can potentially perform spirometry for objective diagnosis 1, 2
• The recent wheezing episode triggered by viral illness is consistent with asthma but could also represent viral-induced wheeze 3, 4
• Arrange formal asthma assessment including spirometry when he recovers from this acute illness 1, 2
• Document response to the prednisolone and salbutamol as part of diagnostic evaluation 2, 3

The viral respiratory infection that triggered his wheeze likely also precipitated this AOM, as viral upper respiratory infections are the primary risk factor for both conditions.