20.2 ENT Disorders

ENT Disorders

Why This Matters for the Exam

Ear and throat complaints are near-universal in pediatric practice, and the exam frequently tests precise diagnostic criteria (how confident must you be before diagnosing acute otitis media?), antibiotic stewardship (who qualifies for observation instead of immediate antibiotics?), and surgical thresholds (when does recurrent throat infection warrant tonsillectomy?).

Acute Otitis Media (AOM)

Diagnostic Criteria

Acute otitis media (AOM) should be diagnosed when one of the following is present:

1. Moderate-to-severe bulging of the tympanic membrane (TM), or
2. New-onset otorrhea not due to otitis externa, or
3. Mild bulging of the TM plus either recent (less than 48 hours) onset of ear pain (or ear-tugging/holding in a nonverbal child) or intense erythema of the TM.

A key exam point: a red tympanic membrane alone, without bulging, is not sufficient to diagnose AOM, since crying alone can redden the TM. Bulging is the central diagnostic finding because it indicates a middle-ear effusion under pressure.

Common Organisms

Management and Watchful Waiting

Not every AOM diagnosis requires an immediate antibiotic. A period of observation, sometimes called watchful waiting or active monitoring, with close follow-up and either a delayed or backup prescription is an appropriate option for a well-appearing child with:

• Unilateral, mild AOM in a child aged 6–23 months, or
• Unilateral or bilateral, mild AOM in a child aged 2 years or older

Watchful waiting is not appropriate for children under 6 months, children with severe symptoms (moderate-to-severe otalgia, otalgia for 48 hours or more, or fever of 39°C or higher), otorrhea, or children with craniofacial abnormalities, immunodeficiency, or a history of complicated AOM. When antibiotics are indicated, high-dose amoxicillin (80–90 mg/kg/day) remains first-line therapy, targeting the most likely pathogens including penicillin-resistant S. pneumoniae.

Exam trap: treating every episode of AOM automatically with antibiotics, or diagnosing AOM from erythema alone without bulging, are two of the most common wrong-answer patterns.

Otitis Media with Effusion (OME)

Otitis media with effusion (OME) is fluid in the middle ear without the signs or symptoms of acute infection — no bulging, no acute otalgia, no fever. It commonly follows resolved AOM (fluid can persist for weeks) or occurs from eustachian tube dysfunction, which is common with adenoid hypertrophy, cleft palate, or Down syndrome.

• Diagnosis: pneumatic otoscopy showing a dull, immobile TM without bulging or acute inflammation; tympanometry (a flat, type B tracing) can confirm.
• Management: OME does not require antibiotics. Most cases resolve spontaneously within 3 months, so watchful waiting with re-examination at roughly 3-month intervals is standard.
• Referral for tympanostomy tubes should be considered if effusion persists beyond 3 months with documented hearing loss, or sooner if there are risk factors for developmental delay (for example, underlying craniofacial or neurodevelopmental conditions) or structural TM changes.

Tonsillitis and Pharyngitis: Viral vs Group A Streptococcal (GAS)

Most acute pharyngitis in children is viral (adenovirus, rhinovirus, Epstein-Barr virus, and others) and self-limited. The key differential is distinguishing viral pharyngitis from Group A Streptococcal (GAS) pharyngitis, because GAS requires antibiotic treatment to prevent suppurative complications and, importantly, acute rheumatic fever.

Centor Criteria (Concept)

The Centor criteria, often applied with the McIsaac age adjustment, estimate the pretest probability of GAS pharyngitis using four clinical findings, each worth one point:

1. Tonsillar exudate
2. Tender anterior cervical lymphadenopathy
3. Fever by history
4. Absence of cough

A higher score raises the pretest probability of GAS and supports the decision to test with a rapid antigen detection test and/or throat culture; a low score (0–1) makes GAS unlikely and testing or antibiotics are generally not pursued. The exam-relevant concept is that Centor is a clinical decision aid used to guide testing, not a substitute for a positive rapid strep test or culture — GAS pharyngitis should be confirmed microbiologically before treating with antibiotics (usually penicillin or amoxicillin) whenever feasible, because clinical impression alone is unreliable.

Tonsillectomy and Adenoidectomy: Indications

Surgical removal of the tonsils, with or without the adenoids, is considered for two broad categories of indication.

1. Recurrent or chronic infection, using frequency criteria as a guide:

• 7 or more episodes of well-documented throat infection in the preceding 1 year, or
• 5 or more episodes per year for 2 consecutive years, or
• 3 or more episodes per year for 3 consecutive years

Each qualifying episode should have objective documentation, such as fever above 38.3°C, cervical adenopathy, tonsillar exudate, or a positive GAS test.

2. Obstructive symptoms, which is now the more common overall indication:

• Adenotonsillar hypertrophy causing obstructive sleep apnea (OSA) or sleep-disordered breathing (snoring, witnessed apneas, restless sleep, mouth breathing)
• Significant dysphagia or growth concerns from mechanical obstruction
• Recurrent peritonsillar abscess, or failure of medical management, particularly with additional risk factors

Exam trap: occasional sore throats that do not meet frequency thresholds, or a single episode of tonsillitis, are not indications for tonsillectomy — observation with symptomatic care is appropriate until frequency criteria, or significant obstructive symptoms, are met.