Bullous myringitis

Background

Ear anatomy

Anatomy of acute otitis media.

• Form of acute otitis media
• Most commonly caused by S. pneumoniae
• Historically strongly associated with pneumonia caused by Mycoplasma pneumoniae, but literature suggests it is a rare cause and may deserve same treatment as AOM

Clinical Features

• Painful fluid filled vesicles on TM
• Possible blood effusion

Differential Diagnosis

Ear Diagnoses

External

• Auricular hematoma
• Auricular perichondritis
• Cholesteatoma
• Contact dermatitis
• Ear foreign body
• Herpes zoster oticus (Ramsay Hunt syndrome)
• Malignant otitis externa
• Otitis externa
• Otomycosis
• Tympanic membrane rupture
  • Otic barotrauma

Internal

• Acute otitis media
  • Bullous myringitis
• Chronic otitis media
• Mastoiditis

Inner/vestibular

• Labyrinthitis, vestibular neuritis
• Meniere's disease
• Sudden sensorineural hearing loss

Evaluation

• Typically a clinical diagnosis

Management

Management aimed at treating acute otitis media

Management

Analgesia

• Acetaminophen/ibuprofen and topical benzocaine (unless perforated TM)

2013 AAP Decision to Treat Guidelines

Age	Otorrhea	Severe Symptoms^	Bilateral without Otorrhea	Unilateral without Otorrhea
6mo-2y	Antibiotics	Antibiotics	Antibiotics	Antibiotics or observation period (wait and see)
≥2y	Antibiotics	Antibiotics	Antibiotics or observation period (wait and see)	Antibiotics or observation period (wait and see)

^Fever > 39C or severe otalgia <48 hrs

Also Consider In:

• Age <6mo
• Ill-appearing
• Recurrent acute otitis media (within 2-4wk)
• Concurrent antibiotic treatment
• Other bacterial infections
• Immunocompromised
• Craniofacial abnormalities

Wait-and-see antibiotic prescription (WASP)

• Rather that routine prescription is an option to avoid over use if the patient does not meet any of the prescription criteria
• If symptoms worsen or persist for 48-72 then caretaker fill the prescription
• Fever (relative risk [RR], 2.95; 95% confidence interval [CI], 1.75 - 4.99; P<.001) and otalgia (RR, 1.62; 95% CI, 1.26 - 2.03; P<.001) were associated with filling the prescription in the WASP group

Antibiotics Options

• Consider treating for a standard of 10 days as opposed to a shorter duration of 5 days to reduce treatment failure in young children
  • Treatment failure for 10 day at 16% and for 5 day at 34% for amoxicillin-clavulanate
  • RTC of 520 children aged 6-23 months

Initial Treatment

High Dose Amoxicillin

• <2 months
  • 30mg/kg/day PO divided q12h x 10 days
  • First Dose: 15mg/kg PO x 1
• 2 months - 5 years
  • 80-90mg/kg/day PO divided q12h x 10 days
  • First Dose: 40-45mg/kg PO x 1
  • Max: 1000mg/dose
• 6-12 years
  • 80-90mg/kg/day PO divided q12h x 5-10 days
  • First Dose: 40-45mg/kg/day PO x 1
  • Max: 1000mg/dose

Treatment during prior Month

1. If amoxicillin taken in past 30 days, Amoxicillin/Clavulanate
   • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
   • Clavulanate increases vomiting/diarrhea
2. Cefdinir 14mg/kg/day BID x7-10 days
3. Cefpodoxime 10mg/kg PO daily x7-10 days
4. Cefuroxime 15mg/kg PO BID x7-10 days
5. Cefprozil 15mg/kg PO BID x7-10 days

Otitis/Conjunctivitis

• Suggestive of non-typeable H.flu

1. Amoxicillin/Clavulanate
   • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
   • Clavulanate increases vomiting/diarrhea

Treatment Failure

defined as treatment during the prior 7-10 days

1. Amoxicillin/Clavulanate
   • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
2. Ceftriaxone 50mg/kg IM once as single injection x 3 days
   • Use if cannot tolerate PO

Penicillin Allergy

1. Azithromycin 10mg/kg/day x 1 day and 5mg/kg/day x 4 remaining days
2. Clarithromycin 7.5mg/kg PO BID x 10 days
3. Clindamycin 10mg/kg PO three times daily
   • Clindamycin does not cover H. influenza and M. catarrhalis and treatment should favor Azithromycin use

Disposition

• Typically discharge