This term covers a spectrum of conditions, which are characterised by the presence of fluid in the middle ear. Fluid may be recognised by tympanic membrane appearance or by assessment of tympanic membrane mobility. Otitis media may be classified according to clinical presentation as either:

• Acute suppurative otitis media (ASOM).
  
• Otitis media with effusion (OME).

Acute suppurative otitis media

This condition is characterised by both:

• Middle ear effusion:

– Otoscopic features include loss of the normal tympanic membrane translucency, loss of the light reflex and yellowish discolouration rather than the usual grey colour of the tympanic membrane

– Reduced tympanic membrane motility – as assessed by pneumatic otoscopy and/or tympanometry

and

• Clinical features of inflammation, that are either:

– Localised (e.g. ear pain) or

– Generalised (e.g. fever, irritability), provided there is no other cause apparent to explain these symptoms.

Note: Be wary of accepting ASOM as the sole diagnosis in an unwell infant with a fever. There may be a coexistent serious bacterial infection. Consider a septic work-up or careful observation.

ASOM is very often preceded by a viral upper respiratory tract infection. The causative bacteria are usually:

• Streptococcus pneumoniae.
  
• Non-typeable Haemophilus influenzae.
  
• Moraxella catarrhalis.

Management

Initial management

• Adequate analgesia:

– Paracetamol – 15 mg/kg p.o. 4–6 hourly (max. 90 mg/kg per day) as required.

• Consider antibiotics:

– Acute symptoms resolve without antibiotics within 24 h in most cases.

– Withhold in children >12 months who are only mildly unwell.

– Commence if child is unwell or distress continues beyond 24–48 h; amoxicillin 15 mg/kg (max 500 mg) p.o. 8 hourly for 5 days or roxithromycin 2.5–4 mg/kg (max. 150 mg) p.o. 12 hourly for 5 days if allergic to penicillin.

Note: Antibiotics do not reduce the incidence of recurrent ASOM or OME (see below).

Follow-up

The key features of ASOM, clinical inflammation and middle-ear effusion, need to be considered separately.

Clinical inflammation

Review in 48 h. If the inflammation has not resolved, consider these possible explanations:

• Wrong diagnosis (e.g. viral URTI, serious bacterial infection).
  
• Failure to take the medication (antibiotics not given or vomited).
  
• Inappropriate antibiotic was prescribed (i.e. bacterial resistance: switch to amoxicillin with clavulanic acid 15 mg/kg (max 500 mg) orally, 8 hourly).
  
• Antibiotic reaction.
  
• Uncommonly, a suppurative complication of ASOM may have developed (e.g. mastoiditis, facial paralysis, labyrinthitis, intracranial infection).

If the medical treatment has been unsuccessful and the child remains symptomatically unwell, early drainage of the ear (myringotomy) with or without insertion of a tympanostomy tube may need to be considered. Refer to an otolaryngologist.

Middle ear effusion

A middle ear effusion is present for a variable period of time following ASOM and may be associated with noticeable hearing loss, particularly if bilateral. A middle ear effusion will be present in approximately:

• 80% of cases at 2 weeks following ASOM.
  
• 40% at 1 month.
  
• 20% at 2 months.
  
• 10% at 3 months.

Review at 3 months is recommended, particularly if symptomatic hearing loss is present. Management – see below (otitis media with effusion).

Recurrent ASOM

ASOM is common in the first 3 years of life and is generally a seasonal condition with a peak incidence in winter and early spring, paralleling the incidence of viral URTI. Prevention of recurrent ASOM may need to be considered during this period, depending on the frequency, severity and duration of infections. Prophylactic measures include:

• Limiting exposure to viral URTI (e.g. by avoiding excessive attendance at large childcare groups).
  
• Long-term prophylactic antibiotics (e.g. co-trimoxazole for 6 weeks).
  
• Insertion of tympanostomy tubes, which should be considered particularly if infections are associated with morbidity and are thought likely to persist for a significant period of time.

Mastoiditis

This is a severe complication of ASOM. Children are unwell; presenting with features of ASOM associated with more severe systemic symptoms and postauricular inflammation (ranging from cellulitis to subperiosteal abscess). Management involves referral to otolaryngologist and i.v. antibiotics. Unless mild, children will require insertion of tympanostomy tubes and drainage of the subperiosteal abscess. Mastoidectomy is performed where cholesteatoma is suspected or in the presence of an additional suppurative complication.

Otitis media with effusion (OME)

A persistent middle ear effusion (which has been present for a variable period of time) can be associated with varying degrees of hearing loss, behavioural, language and educational difficulties. OME usually resolves spontaneously over time. Factors contributing to persistence include recurrent upper respiratory tract infection, recurrent ASOM, poor eustachian tube function and exposure to tobacco smoke.

Management

Medical

• Antibiotics: for symptomatic cases that have not resolved in 3 months, a prolonged course of antibiotics (amoxicillin 15 mg/kg (max. 500 mg) 8 hourly for 3 weks) will usually result in resolution.
  
• No other medical treatment has proven benefit (except for steroids, which are not recommended in the treatment of OME).
  
• Eustachian tube exercises (auto-inflation) are of limited value because of the difficulty of adherence in children.

Tympanostomy tubes

Tympanostomy tubes provide good short-term benefit, but their long-term value is widely debated. It does not cure the underlying eustachian tube dysfunction responsible for OME, but temporarily removes the symptoms by providing an alternative means for middle ear ventilation. Adenoidectomy may be beneficial (by removing a reservoir of infection from the nasopharynx), particularly in children requiring recurrent tympanostomy tube insertion. The long-term impact of tympanostomy tube insertion on language, literacy and cognitive function is the subject of ongoing research.

Consider insertion of tympanostomy tubes only if:

• Middle ear effusion present for at least 3 months and appears likely to persist long term,

and

• significant symptoms are present: either recurrent ASOM or functionally significant hearing loss (e.g. speech delay, behavioural disturbance or poor school performance).

OME and ASOM are commonly related to URTI and are therefore more common in winter and early spring. Inserting tubes towards the end of this period should be avoided, in the expectation that there may be resolution with the onset of warmer weather.

The benefits of temporary alleviation of symptoms by tympanostomy tube insertion need to be balanced against the disadvantages:

• Need for general anaesthesia and surgery.
  
• Tubes usually remain in situ for only 6–9 months (although longer-stay tubes are available) and the reinsertion rate of tubes is ∼25%.
  
• Tympanic membrane perforation occurs at a rate of approximately 1% per year that tubes remain in situ. A range of other tympanic membrane and middle ear complications are associated with tubes.
  
• Otorrhoea occurs in up to 25% of cases. It is often associated with an URTI, and may also occur because of external contamination (e.g. swimming or bathing without ear protection).

Management of discharging ears in children with tympanostomy tubes

• Ear toilet; gentle removal of excess discharge and debris from the outer external canal using cotton wool.
  
• Topical antibiotics, e.g. ciprofloxacin.
  
• For refractory discharge:

– Ear swab.

– 1.5% hydrogen peroxide ear washes.

– Refer to an otolaryngologist.

– Consider possibility of underlying immunodeficiency or cholesteatoma.

Clinical features

Commonly occurs due to water contamination following swimming or in children with dermatitis of the external auditory canal. It is characterised by pain (often severe) and:

• Inflammation of the ear canal, which may include the tympanic membrane (mobility of the tympanic membrane on pneumatic otoscopy excludes otitis media).
  
• Pre-auricular tenderness.

The combination of fever and sore throat is a common presenting problem in children. Determining the aetiology and deciding whether to treat with antibiotics can be difficult.

Background

Most sore throats are due to a viral infection (almost all in children <4 years of age). The only clinically important bacterial pathogen is group A â–haemolytic streptococcus (GABHS), Streptococcus pyogenes.

• GABHS is found in around 20–30% of older children presenting with an acute sore throat.
  
• GABHS colonises the throat in some normal children (up to 20%).
  
• Distinguishing colonisation from acute infection is a major problem. A child with a sore throat may be colonised with GABHS and therefore have a positive throat swab (or a positive antigen test), yet the cause of the episode may be a viral infection.
  
• GABHS is more likely if the child is 4 years of age or older, has tenderness and enlargement of the tonsillar cervical lymph nodes, inflammation of the tonsils and pharynx (pharyngotonsillitis), unilateral signs or a generalised erythematous (scarlatiniform) rash.
  
• The presence of tonsillar exudate is not helpful in distinguishing viral infection from GABHS.
  
• GABHS is less likely if the child has associated coryza, cough, generalised lymphadenopathy or splenomegaly.
  
• Streptococcal serology (ASOT, antiDNase-B titre) can only be used to make a retrospective diagnosis (rise in titre between baseline and 3 weeks later).
  
• Penicillin reduces the duration of symptoms, possibly by up to a day or more. Penicillin reduces the incidence of uncommon suppurative complications (e.g. quinsy) and acute rheumatic fever. However, penicillin to prevent acute rheumatic fever is of questionable use as this is now rare except in some indigenous communities and developing countries.

Practical management

Children who probably do not need antibiotics are those aged <4 years and/or those with associated cough or coryza, unless they are unwell enough to require hospitalisation.

Children who might benefit from antibiotics are those aged >4 with marked pharyngotonsillitis, tender tonsillar cervical nodes, and without cough and coryza.

• Send a throat swab for culture and give oral phenoxymethylpenicillin 250 mg (500 mg if >10 years) 12 hourly.
  
• Erythromycin 15 mg/kg (max. 500 mg) 8 hourly or roxithromycin 2.5 mg/kg (max. 150 mg) 12 hourly may be used for children with true penicillin allergy.
  
• If the throat swab does not grow a GABHS (the result is normally available 48–72 h later) the antibiotics can be stopped. If GABHS is grown, continue antibiotics for a total of 10 days.

In populations with high rates of acute rheumatic fever (e.g. Aboriginal Australians in remote/ rural settings), all sore throats should be treated with antibiotics and throat swabs are not needed.

Infectious mononucleosis is a relatively common cause of acute pharyngitis in older children. The diagnosis often becomes apparent when there is no response to penicillin, other characteristic features develop (e.g. generalised lymphadenopathy, splenomegaly, mild jaundice and rashes) and the illness follows a more prolonged course.

Quinsy (peritonsillar abscess)

Infection can extend beyond the tonsil as cellulitis (peritonsillar cellulitis) or as a peritonsillar abscess (quinsy). In addition to features of severe tonsillitis, quinsy presents with drooling, a ‘hot potato’ voice, and trismus. Inflammation of the hemipalate adjacent to the tonsil is evident and an area of fluctuance (perceived as a softening) can be palpated. In the earlier cellulitic stage, the condition will settle with i.v. antibiotics, but where an abscess is present, drainage is necessary. Refer to an otolaryngologist.

Recurrent acute pharyngitis/tonsillitis

Recurrent sore throats are a normal part of growing up for many children. Many of these children have recurrent viral pharyngitis. True recurrent GABHS pharyngotonsillitis is much less common but often over-diagnosed.

A variety of strategies have been used to reduce recurrences of GABHS pharyngotonsillitis. None of these is universally effective in preventing recurrent episodes and each has its own disadvantages.

• Use of another antibiotic to attempt eradication of GABHS (e.g. amoxicillin/clavulanic acid).
  
• Use of low-dose prophylactic penicillin.
  
• Treatment of culture-positive family members.
  
• Tonsillectomy. Tonsillectomy (with or without adenoidectomy) probably works by removing a reservoir of GABHS infection. It should be considered if the pattern of infection (i.e. frequency, severity and duration of infections) is such that significant morbidity is expected to continue for a prolonged and unacceptable period of time. The presence of associated airway obstruction may influence treatment choice.

Children with suspected recurrent GABHS pharyngotonsillitis should have a throat swab taken during an acute episode to aid in treatment decisions. Streptococcal serology may also be of value.

See chapter 12, Sleep).

This is usually due to bleeding from the anterior nasoseptal vessels, often in association with nasal crusting or nose picking. Acute bleeding usually settles with local pressure to the lower nasal septum, but occasionally the application of a cottonwool pledget soaked with a topical decongestant (e.g. ephedrine) is necessary.

Recurrent bleeding can be treated by the application of an antibiotic ointment if significant nasal crusting is present, or by cautery if enlarged blood vessels are seen (use a silver nitrate stick following the application of a topical anaesthetic and decongestant, e.g. co-phenylcaine spray – lignocaine (lidocaine)/phenylephrine). Epistaxis in children is very unlikely to be due to a nasal tumour or a previously undiagnosed coagulopathy.

Nasal trauma

Treatment is required for either cosmesis or drainage of septal haematoma.

Cosmesis

A nasal deformity due to a displaced nasal fracture should be reduced within 7–10 days of injury. The presence of a bony deformity due to a nasal fracture is best determined at about 5 days following the injury, once the soft tissue swelling has resolved. The decision to reduce the nasal fracture is based on clinical grounds and radiology is unhelpful.

Septal haematoma

• This can occur after nasal trauma, regardless of whether a fracture is present or not. It invariably leads to septal abscess formation with cartilage destruction and nasal collapse.
  
• It presents with nasal obstruction and pain associated with a bulge of the septum that can be confirmed by palpating with an instrument (e.g. wax curette) following application of a topical anaesthetic. Treatment involves incision and drainage, nasal packing to prevent recurrence and antistaphylococcal antibiotics.

Oral/oropharyngeal trauma

This invariably occurs after a fall with a stick or similar object in the mouth and may sometimes be associated with a significant injury.

Admit and evaluate if:

• Unable to feed.
  
• Upper airway obstruction.
  
• Significant laceration, requiring debridement, closure or both.
  
• Significant retropharyngeal injury.
  
• Suspicion of injury to the internal carotid artery. The internal carotid artery lies posterolateral to the tonsil. An injury to this region may be associated with injury to the internal carotid artery whether the trauma is blunt or sharp. Internal carotid artery injuries are rare; they are usually due to blunt trauma causing intimal disruption and progressive thrombosis and they typically present with neurological signs over a period of 24 h.

Involvement of the retropharynx may not be obvious by oral examination, particularly for injuries that penetrate the soft palate. Investigate by:

• Lateral cervical spine radiograph (look for widened retropharynx, evidence of cervical spine injury, or presence of foreign material).
  
• Flexible nasopharyngoscopy.

Consider involvement of the teeth in cases of oral trauma; see chapter 22, Dental conditions

Aural trauma

Trauma to the external auditory canal is usually associated with bleeding, but it is an insignificant injury and requires no treatment. The tympanic membrane can be perforated by direct trauma or a pressure wave (e.g. a slap across the ear or diving). Acute tympanic membrane perforations usually heal within weeks and do not require acute intervention. Topical antibiotics are recommended for water-related injuries. Direct trauma may rarely cause ossicular disruption, facial paralysis or inner ear damage (with complete deafness and vertigo). Follow-up at around 4 weeks after injury is required to ensure perforations have healed.

The first attempt at foreign body removal is always the easiest and should be undertaken by an experienced clinician with the appropriate instruments and good illumination. Take into account the child’s developmental stage and their level of anxiety in planning this procedure. Failure of the initial removal may lead to an otherwise unnecessary general anaesthetic.

Ear

Foreign bodies in the external auditory canal are best removed with a hook-shaped instrument, which is passed behind the foreign body and then used to pull it out. Grasping instruments, such as forceps, invariably lead to the foreign body being displaced further medially. Suction may also be useful.

Nose

The technique for the removal of nasal foreign bodies is the same as for foreign bodies in the external auditory canal. A topical anaesthetic (e.g. co-phenylcaine) should be applied before the attempted removal. The risk of inhalation of a nasal foreign body is minimal and therefore acute removal should be deferred until appropriate personnel and equipment are available.

Fish bone in pharynx

A fish bone usually lodges in the tonsil or at the base of the tongue and therefore can be seen on oral examination and removed after the application of a topical anaesthetic. If the fish bone cannot be seen during the oral examination, a more thorough examination by nasopharyngoscopy is required. Fish bones rarely reach the oesophagus and so oesophageal evaluation is usually unnecessary. Where a fish bone is not found, despite a suggestive history, the child should be reviewed until symptoms resolve and an examination under general anaesthetic considered. Although fish bones are radiolucent, radiology (particularly CT) may be helpful to detect the presence of complications when symptoms persist.

Oesophagus

The vast majority of swallowed foreign bodies pass without difficulty. If a foreign body becomes lodged in the oesophagus, it usually does so in the upper oesophagus, at the level of the cricopharyngeus. Lower oesophageal foreign bodies suggest the presence of underlying oesophageal pathology (e.g. stricture).

If a swallowed object reaches the stomach it will almost always pass without incident. Two types of object, however, may cause problems:

• Long, thin objects (e.g. hairpins and locker keys) may impact at the duodenojejunal flexure.
  
• Button batteries, if held up at any point in the alimentary canal, may release alkali, causing local necrosis and perforation. Their removal is a matter of urgency.

Radiographs (including neck, chest and abdomen) should be taken if there are symptoms suggestive of oesophageal impaction (e.g. drooling and dysphagia), or if long, thin objects or button batteries have been swallowed. Oesophageal foreign bodies impact in the coronal plane, whereas tracheal lodgement occurs in the sagittal plane. Radiolucent foreign bodies may be imaged by barium swallow. If an object is impacted in the oesophagus, endoscopic removal is required.

Tracheobronchus

See chapter 36, Respiratory conditions.