11.3 Otitis, Pharyngitis, Sinusitis & Hearing

Otolaryngology is clinical category #4 by exam volume. This is the CPNP-PC's highest-frequency infectious-disease office work: ears, throats, sinuses, hearing, cerumen, and the bead in the nose. Domain II wants a physical diagnosis that matches AAP criteria. Domain III wants the right drug — or no drug — and a hearing path that does not wait for the child to "talk later."

Acute otitis media: diagnose the bulge, then decide to treat or observe

AAP diagnosis of acute otitis media (AOM) is not "the ear looks a little red." Diagnose AOM when there is:

• Moderate-to-severe bulging of the tympanic membrane, or
• New otorrhea that is not acute otitis externa (this is not "swimmer's ear" drainage), or
• Mild bulging plus recent ear pain (<48 hours; holding or tugging in a nonverbal child) or intense TM erythema

A middle-ear effusion without those acute inflammatory signs is otitis media with effusion (OME), not AOM. Do not treat OME with oral antibiotics because the TM is dull.

Pneumatic otoscopy (immobility) supports effusion. Bullous myringitis is still AOM, not a separate antibiotic class.

Treat versus observe (AAP 2013, still the exam spine)

Treat pain with age-appropriate ibuprofen or acetaminophen whether you observe or treat.

First-line antibiotic: high-dose amoxicillin (80–90 mg/kg/day divided twice daily) when a decision to treat has been made and the child has not received a beta-lactam in the past 30 days, does not have concurrent purulent conjunctivitis, and is not penicillin-allergic. Concurrent conjunctivitis-otitis points to nontypeable Haemophilus influenzae — use amoxicillin-clavulanate. Recent amoxicillin or failed 48–72 hour amoxicillin: amoxicillin-clavulanate. Duration commonly taught from AAP: 10 days if under 2 years or severe; 7 days at 2–5 years; 5–7 days if 6 years or older with mild–moderate disease.

OME: watchful waiting, hearing, language, tubes

OME is fluid without AOM signs. After AOM, effusion may last weeks. Watchful waiting for 3 months is appropriate in a child who is not at extra language risk, with hearing and language surveillance. Antihistamines, decongestants, and routine oral or nasal steroids are not AOM/OME cures.

Tympanostomy-tube referral when OME is persistent with documented hearing loss, speech or language delay, recurrent AOM with persistent effusion, or in at-risk children (cleft palate, Down syndrome, existing hearing loss). You do not place tubes at the first dull TM. Uncomplicated tube otorrhea is often managed with topical fluoroquinolone drops, not automatic oral therapy.

Otitis externa and cerumen

Otitis externa (OE) is an infected ear canal: pain with tragus or pinna traction, swollen canal, debris, and a TM you may not see. It is swimmer's ear, not AOM. Treat with topical fluoroquinolone drops (ofloxacin, or ciprofloxacin with dexamethasone when inflammation is prominent). Keep the canal dry. A wick helps if the canal is closed. Oral antibiotics are for cellulitis, fever, or an immunocompromised host — not for routine OE. Avoid aminoglycoside-containing drops if the TM is not known to be intact.

Cerumen removal is a PNCB blueprint office procedure. Remove wax when it blocks the exam, contributes to hearing complaints, or hides the TM you need to diagnose AOM versus OME. Methods: curette, irrigation, or suction after you have a reason to believe the TM is intact. Do not irrigate if there are tubes, a known perforation, the only hearing ear, or active OE. Document what you saw after the canal was clear. Impacted cerumen is not an indication for oral antibiotics.

Clinic vignette. A 4-year-old's TM is "red" but not bulging, landmarks are visible, and there is no pain. That is not AOM. Look again after cerumen removal if the canal is full; treat OE if tragus pain dominates; observe OME if fluid is present without acute inflammatory criteria.

Streptococcal pharyngitis

Viral pharyngitis dominates childhood sore throat. Group A streptococcus (GAS) is the treatable bacterial exception because of suppurative complications and acute rheumatic fever.

Test before you treat. Use a rapid antigen detection test (or a nucleic-acid test per practice protocol). In children, a negative rapid antigen test is followed by a backup throat culture (or an equivalently sensitive molecular test). Do not treat a 6-year-old with amoxicillin because the Centor score is 3. Centor/McIsaac scores are poorly validated in young children and should not replace testing.

Do not routinely test children under 3 years for GAS; rheumatic fever is rare in that age, and viral illness dominates — unless there is a household index case or an outbreak.

Scarlet fever (sandpaper rash, strawberry tongue, Pastia lines, circumoral pallor) is GAS with an erythrogenic toxin. Some older teachings treat on sight. Still prefer microbiologic confirmation when it can be obtained — viral exanthems mimic the rash, and the CPNP-PC is not guessing antibiotics for "a red sandpaper vibe."

First-line treatment is penicillin or amoxicillin for 10 days (or benzathine penicillin G intramuscularly if adherence is in doubt). Azithromycin is for true penicillin allergy, not for convenience; macrolide resistance exists. Return to school after at least 12–24 hours of antibiotics and when afebrile. A chronic carrier with a positive test and no illness is not treated the same as acute pharyngitis; do not give repeated courses for a well child who tests positive at every well visit.

Acute bacterial sinusitis

Most colds are viral for 7–10 days with cough and colored drainage that does not equal bacterial sinusitis. AAP acute bacterial sinusitis is a clinical diagnosis when any of these is present:

1. Persistent symptoms ≥10 days without improvement, or
2. Worsening ("double sickening") — new or worse fever, cough, or nasal discharge after an initial improvement, or
3. Severe onset: fever ≥39°C plus purulent nasal discharge for at least 3 consecutive days

Treat with amoxicillin or amoxicillin-clavulanate depending on risk for resistance (recent antibiotics, moderate–severe disease, daycare — follow current AAP dosing). Do not CT a first episode of uncomplicated sinusitis. Intranasal saline and INCS may comfort; oral decongestants are not the pediatric plan (see 11.2).

Hearing, ototoxins, and the failed screen

Universal newborn hearing screening is the floor. EHDI timing: screen by 1 month, diagnosis by 3 months, intervention by 6 months (1–3–6). A failed screen is a diagnostic audiology referral, not "we will see if they talk."

Speech or language delay → audiology now, even if the newborn screen passed. Recurrent AOM and persistent OME are hearing-risk histories; plot language, not only TM color. Ototoxic exposures (aminoglycosides, cisplatin, loop diuretics) belong in the history of a child with new hearing concerns. Congenital CMV is a leading non-genetic cause of pediatric hearing loss; a passed newborn screen does not exclude later CMV-related loss.

Foreign bodies: ear and nose

Unilateral foul, bloody, or purulent nasal discharge is a nasal foreign body until proven otherwise. Button batteries and paired magnets are emergencies — they burn and necrose; do not delay ENT. Do not irrigate organic objects (beans swell) or batteries. Remove a visualized, graspable, non-battery object if you have the tool and the child can be held still; otherwise refer. Ear canal foreign bodies: do not chase a bead with irrigation if you cannot see the TM. Insects can be immobilized with mineral oil only if the TM is intact before removal.

Exam traps. Treating a red TM without bulging. Observing a 10-week-old with AOM. First-line azithromycin for AOM. Oral antibiotics for uncomplicated OE. Treating pharyngitis without a test because Centor is "positive." Calling a 5-day cold "sinusitis" because the snot is green. Waiting on speech delay because the newborn screen was normal. Irrigating a nasal battery.

Bulge or non-OE otorrhea, high-dose amoxicillin when indicated, observe the right older child, OME waits with hearing checks, OE is drops, strep is tested, sinusitis needs 10-day/worsening/severe-3-day criteria, and hearing problems leave the office with an audiology plan. That is ENT on this exam.