What’s the difference between a kid with a 103°F temperature who has otitis media and a kid with a 103°F temperature and meningitis? How do you walk into a room and say, “This one’s okay, this one’s okay, this one is super sick?”
I use the mnemonic “TICKLES.” I was very concerned about missing a septic kid in my early days as a PA. This mnemonic is flawless; it gives you the right set of eyes to ask, “Is my kid really sick or not?”
- Tone: Do they have a weak tone or a strong tone? Are they pushing you away? I want a kid who fights my ear exam. You have to document this in your chart and communicate it to your doc.
- Irritability: A sick kid should not like you, but they should like their parent. I and C go together.
- Consolable: I document if a child is irritated by the provoking examiner and consoled by their parent.
- K is for Cry: This is aligned with their tone. Is the cry loud and vigorous or is it wimpy? A wimpy cry is concerning, especially when the pitch of the cry doesn’t change during a puncture.
- Labor: Are they laborious in their breathing? When taking care of a sick kid, you have to take off their shirt so you can look at their chest wall. Can you picture a one-year-old with retractions? If you don’t know what it looks like, you need to YouTube it so you never miss it. Respiratory rate is really important, especially in sick kids.
- Environment: Are they appropriately stimulated by the environment? This is age-relative. For a baby, it might be a startle reflex or the moro reflex. You need to know how to stimulate older kids to make sure they’re engaging with you appropriately. I used to go in the room with a SpongeBob sticker on my forehead and say, “I was going to bring you a SpongeBob sticker but I can’t find it. Nurse, do you know where the SpongeBob sticker is?” The kid’s like, “It’s on your head!” And I say, “It’s not on my head, I’m an adult. There’s no sticker.” The more they try to convince me the sticker’s on my head, the more I know they’re fine.
- Suckling: Get a good history of their feeding. The kid with otitis media will cut down on food but they’ll still drink about half of what’s normal. Kids with a bad infection won’t ingest anything. You need to communicate this on your charts and to your attending docs.
I want to review the basics here because in reviewing this on my own, I found practice-changing information.
Diagnosing Otitis Media
Pneumatic insufflation was taught in physician assistant and nurse practitioner school as great diagnostic testing, but Sanford’s is not recommending it. Instead, we’re going to diagnose based on bulging, discharge and redness.
- Bulging: There will be bulging of the tympanic membrane in moderate to severe cases. If it’s mild bulging but the kid has other symptoms, we can still diagnose it.
- Discharge: Any kind of discharge from the ear means otitis media.
- Redness: If the tympanic membrane is really erythematous that’s a diagnosis.
Treating Otitis Media
You should also categorize it, mild, moderate or severe, because antibiotic recommendations change depending on severity. Severe otitis media means moderate to severe ear pain going on 48 hours or a temperature greater than 102°F. The pediatric literature says you should start antibiotics in this case.
It’s also recommended that you treat otitis media in kids under two years old. That’s not a time to be passive. This is a practice-changing piece of information for me. JAMP is saying an 18-month-old with otitis media should absolutely be treated with antibiotics. However, if they’re older than two, observation is reasonable.
This is the art of medicine. Anybody can write a script for amoxicillin, but that does not make you a good clinician. A good clinician will talk the parent out of amoxicillin and make them feel good about it. This path has shown favorable results when there’s ear pain but no fever.
If they haven’t had antibiotics, a case of conjunctivitis or a history of acute recurrent otitis media, amoxicillin or Augmentin is recommended. What are the three major germs in the ear? Strep-pneumoniae, H-flu and M-cat. Strep-pneumoniae is a gram-positive and the other two are gram-negative. Amoxicillin’s beautiful in this situation.
Augmentin is like a stronger amoxicillin. When should we use Augmentin (amoxicillin clavulanic acid)? In kids that took another antibiotic in the last 30 days or failed to respond to amoxicillin. Remember, it can take 72 hours for an antibiotic to really work. If you’re at 48 hours, we really haven’t given it enough time. In cases where you have conjunctivitis and otitis media at the same time, Augmentin is preferred. The same is true in cases of recurrent acute otitis media.
Amoxicillin is still the preferred antibiotic for adults with acute otitis media if they’ve had no antibiotics in the last month. If they’ve had antibiotics within a month, you can use Augmentin or fluoroquinolone. The dosing of Levaquin is a five-day course. All other options are a 10-day course.
What does conjunctivitis have to do with otitis media? I want to share this with you because it changed my practice. There is now a condition called conjunctivitis otitis syndrome. There’s communication, albeit indirectly, between the eye and the ear between the eustachian tube and lacrimal glands. They combine at the back of the throat, so you can get a concomitant infection due to H-flu in the eye and the ear.
If you have someone with conjunctivitis, you need to look at the ear, even if they have no pain, especially pediatric patients. When you have conjunctivitis and a bulging tympanic membrane on the same side, treat with Augmentin. This is the standard of care now because 25% of patients with conjunctivitis have concurrent otitis media even in the absence of ear pain.
I think a lot of us are kind of weak with the eyes. I want to give you two tools so you won’t get burned by an eye. You have to do these two things:
Visual acuity is to the eye what an EKG is to the heart. What does that mean? When you get so good at chest pain you don’t have to do EKGs anymore, you can take care of eye complaints without visual acuity. What am I saying? You can’t do it. To manage an eye complaint without visual acuity is like taking care of belly pain without vital signs. It’s indefensible.
Every single eye complaint gets visual acuity, whether it’s conjunctivitis, corneal abrasion, I don’t care. It doesn’t have to be the Snellen chart; it just has to be visual acuity. It doesn’t matter how. The patient says, “I don’t have my glasses. I can’t read anything.” That’s okay. You ask, “Can you tell me how many fingers I’m holding up?” That’s still visual acuity.
The limbus is the clear area, about a millimeter, right around the iris of the eye. If the limbus is clear, it tells me there’s a superficial problem going on. It needs to be looked at and documented.