Returns  48 hours later with continuing symptoms:
  temperature increase to 39 degrees C rectal;
  ill appearing. Left ear, effusion only.

Tympanogram: Compliance 0.0 cc, gradient: no peak.

What treatment options would be available for this child?

This child has a bulging right sided acute otitis media accompanied by high fever, despite treatment for 48 hours with oral amoxicillin 40 mg/kg per day. The tympanogram is flat. A compliance less than 0.2 cc and gradient with no peak represents a high likelihood that the middle ear is full of fluid. In addition, copious opaque fluid can be seen behind the TM, and there is a lot of erythema, especially in the region of the lateral process.

It is important to be sure that this child has no other complications such as pneumonia or meningitis. Perform a complete physical, examine the neck carefully to be sure it is supple. Listen to the lungs for any evidence of pneumonia, and check the respiratory rate, looking also for retractions that might indicate pulmonary involvement.

Switching this child to Augmentin (amoxicilin/clavulanate)with amoxicillin at a dose of 90 mg/kg/day would be one way to cover a resistant pneumococcus as well as beta-lactamase-positive strains of M. catarrhalis or H. influenzae.  An alternative treatment includes intramuscular ceftriaxone.

A tympanocentesis at this stage would also be an option, to relieve the discomfort, drain the ear, and obtain a culture.

We would also recommend a nasopharyngeal swab culture, if available, to evaluate for any pathogens this child may be carrying. If the child is not improving after another 48 hours, a nasopharyngeal culture may help in selection of an appropriate antibiotic. Studies have shown high negative predictive value of the nasopharyngeal culture for middle ear pathogens. If the nasopharyngeal culture is negative for a specific type of bacteria, it is very unlikely that the bacteria is in the middle ear. However, a positive nasopharyngeal culture for a given bacterial strain is not highly correlated with the presence of that strain in the middle ear fluid.

We like to maintain daily telephone contact with the parents of children such as this to assure ourselves that they are improving and to provide further assistance if the child has continuing symptoms.