A 15-month-old child with recurrent otitis media.

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DR REYNOLDS: Sam is a 15-month-old child who has recurrent otitis media. He lives near Boston with his mother, father, and a healthy older brother, aged 2 years 9 months. Sam is cared for at home while his parents are at work. Born at term in October 2000 by elective repeat cesarean delivery to a healthy 37-year-old gravida 2, para 2 mother after an uncomplicated pregnancy, Sam had a normal hearing screen at birth. At the age of 5 months he had his first episode of acute otitis media, manifested by spontaneous perforation and draining of pus from the left ear. He was treated with amoxicillin, 80 mg/kg per day, and his eardrum was found intact at a subsequent visit. In May, June (twice), August, September, and November of 2001, Sam had 6 more episodes of acute otitis without perforation. His pediatrician, Dr T, noted that the diagnoses were made based on pneumatic otoscopy showing pus behind an immobile tympanic membrane when the patient was symptomatic with cold symptoms, irritability, and/or fever. Sam was treated with amoxicillin, azithromycin, and amoxicillin-clavulanate. Revisits showed a normal tympanic membrane between each episode. In early December 2001, Dr T discussed the relative merits and risks of watchful waiting, prophylactic antibiotics, and tympanostomy tube placement with Sam’s parents. At the time of the interview, Mrs G, Sam’s mother, reported that he had been taking prophylactic amoxicillin, 250 mg/d, for 1 month and had not had another acute otitis media episode. Sam’s past medical history is significant for a buckle fracture of his right radius and ulna. He has had normal growth and has achieved appropriate developmental milestones. His immunizations are up to date, including pneumococcal conjugate vaccine. His only medication is amoxicillin; he has no known drug allergies. He is not exposed to cigarette smoke. Family history is significant for first cousins on his paternal side with recurrent otitis media. Physical examination showed a healthy 15-month-old boy. His weight was 22 lb 14 oz (25th percentile), length 31.5 in (50th percentile), and head circumference 19.75 in (95th percentile). His ear examination results were normal by pneumatic otoscopy bilaterally. Sam has not had a hearing test since birth. His IgG level was borderline low when tested in September 2001 at 288 mg/dL (normal for age, 300-1500 mg/dL); his IgA level was also at the lower limit of normal. His parents are frustrated by his recurrent ear infections and hope that the prophylactic antibiotics prevent future infections.