Febrile Child OSCE - Otitis Media

Case Overview

• Age/Sex: 6-year-old male
• Occupation: Primary school pupil (first grade)
• Setting: General practice (parent bringing child)
• Chief complaint: "He's had a fever and keeps pulling his ear."

Patient Script

Who I Am

I'm his mother — my son is a 6-year-old boy who attends first grade.

What Brings Me In

He has a fever and has been pulling at his right ear for the last couple of days, and I'm worried he might have an ear infection.

My Story

He started feeling unwell 2 days ago with a runny nose and a bit of a cough, then developed a fever yesterday evening up to about 39°C, and since then he's been touching and tugging his right ear a lot and is more irritable than usual. He slept poorly last night and has reduced appetite today. I noticed him cry when I touched around his ear this morning. There was a little bit of clear fluid on his pillow once, but I haven't seen pus or continuous drainage. He was at daycare last week where several kids had colds. He also went to a swimming lesson one week ago (just one session). I tried paracetamol at home which helped his fever a bit.

My Medical Background

• Past medical history: no chronic illnesses, no previous ear infections I can remember
• Medications: paracetamol PRN (given once last night and once this morning)
• Allergies: none known
• Social: lives with parents and a 3-year-old sibling who had a cold last week; non-smoking household
• Immunisations: up to date according to our child health clinic notes

What I Think & Worry About

• I think he might have an ear infection.
• I'm worried it might get worse or that he could lose his hearing.
• I want to know if he needs antibiotics or if we can wait and see.

If You Ask Me About Other Symptoms...

• Runny nose/cold symptoms: "Yes, he had a runny nose and a bit of cough starting two days ago."
• Vomiting/diarrhoea: "No vomiting, no diarrhoea — he just hasn't eaten much."
• Ear discharge: "I saw a tiny bit of clear fluid on his pillow once, nothing yellow or smelly."
• Recent trauma/foreign body: "No, he hasn't put anything in his ear as far as I know; I did once try to clean wax with a cotton bud a few weeks ago."
• Swimming: "He had a swimming class a week ago, but he didn't complain then."
• Hearing/communication: "He seems a bit slower to respond sometimes today, but I think that's because he's tired and grumpy."
• Other family illnesses: "His little sister had a cold last week."

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Clinical Summary

Examination

• General: alert but irritable, consolable; appears mildly unwell
• Temperature: 38.8°C
• Heart rate: 120 bpm (appropriate for age/fever)
• Respiratory rate: 22/min
• O2 saturation: 98% on room air
• Weight: approximately 20 kg (estimated)
• ENT/Head: right ear: external ear and canal without obvious discharge, tympanic membrane erythematous and bulging with loss of normal landmarks; reduced mobility on pneumatic otoscopy; left tympanic membrane normal in colour and mobility
• Neck: small, tender right preauricular/cervical lymph node
• Lungs: clear to auscultation, no wheeze
• Neurological: normal; no neck stiffness or focal deficits
• No postauricular swelling or signs of mastoiditis

Investigations

• Tympanometry: Type B on the right (flat tracing) (consistent with middle ear effusion)
• Full blood count: WCC 13.5 x10^9/L (mild leukocytosis)
• C-reactive protein (CRP): 28 mg/L (mild–moderate elevation)
• Urine dipstick: negative (rules out UTI as source of fever)
• (No imaging indicated at this stage)

Diagnosis

• Primary diagnosis: Acute otitis media (AOM), right ear

  • Evidence: acute onset of ear pain/irritability and fever, ear tugging, bulging and erythematous tympanic membrane with reduced mobility on pneumatic otoscopy, Type B tympanogram, and mild systemic inflammatory response.

• Differentials with reasoning:

  • Otitis externa: less likely because the tympanic membrane is involved (bulging erythematous TM) and there is no significant canal swelling or purulent otorrhoea.
  • Viral upper respiratory infection causing referred ear pain: possible contributor (runny nose, cough) but tympanic membrane findings point to AOM.
  • Foreign body in ear: unlikely — no visible object in canal and TM abnormality indicates middle ear problem.
  • Early mastoiditis: unlikely currently — no postauricular swelling, erythema, or protrusion of the auricle; should be reconsidered if symptoms worsen.

Management

• Symptomatic care:
  • Analgesia: paracetamol 15 mg/kg per dose every 4–6 hours as needed (max per day per local guidance), and ibuprofen 5–10 mg/kg per dose every 6–8 hours as needed for persistent pain/fever (if no contraindications).
  • Advise against using cotton buds or trying to clean the ear further.
• Antibiotic strategy:
  • For this 6-year-old with unilateral AOM, fever ~38.8°C and moderate ear pain, either offer a short course of oral antibiotics (e.g., amoxicillin as first-line) or a safety-net (delayed) prescription depending on local guidelines and parental preference.
  • Example dosing: amoxicillin 40 mg/kg/day divided three times daily for 5 days (use weight-based dosing and local formulary recommendations; consider higher dose if otitis is severe or in areas with high resistance).
  • Start antibiotics promptly if severe symptoms develop (persistent high fever, worsening pain, otorrhoea), if symptoms do not improve within 48–72 hours, or if the child becomes systemically unwell.
• Follow-up and safety-netting:
  • Review or telephone follow-up in 48–72 hours or earlier if worse (increasing fever, continuous ear drainage, severe pain, signs of mastoiditis, reduced responsiveness or difficulty breathing).
  • Seek immediate care if postauricular swelling, protrusion of the ear, or new neurological signs occur (concern for mastoiditis/complication).
• When to refer/admit:
  • Urgent ENT review/admission for suspected complications (mastoiditis, intracranial spread), recurrent AOM (e.g., ≥3 episodes in 6 months or ≥4 in 12 months), or persistent middle ear effusion affecting hearing.

Key Learning Points

• Acute otitis media is diagnosed clinically — bulging tympanic membrane with erythema and reduced mobility on pneumatic otoscopy are key diagnostic signs.
• Management balances analgesia and observation versus antibiotics; use age, severity, and ability to follow up to guide immediate antibiotic prescribing or a safety-net approach.
• Safety-netting is essential: advise parents what to watch for (worsening fever/pain, ear drainage, signs of mastoiditis, poor oral intake or responsiveness) and arrange review within 48–72 hours.