Overview
Definition:
Teething refers to the process of infant teeth erupting through the gums, often associated with discomfort and irritability
Otitis media (OM) is an inflammation of the middle ear, typically caused by bacterial or viral infection, presenting with pain and potential systemic symptoms.
Epidemiology:
Teething commonly occurs between 6-24 months of age, with peak incidence around 12-18 months
Otitis media is the most common bacterial infection in young children, with a peak incidence between 6-18 months, often following a viral upper respiratory infection
Up to 80% of children experience at least one episode of OM by age 3.
Clinical Significance:
Accurate differentiation is crucial as teething is a benign physiological process managed with symptomatic relief, while otitis media requires medical evaluation and potential antibiotic treatment to prevent complications
Misdiagnosis can lead to delayed treatment of infection or unnecessary interventions for a normal developmental stage.
Clinical Presentation
Symptoms:
Teething: Increased drooling
Chewing on objects
Mild irritability or fussiness
Sleep disturbances
Low-grade fever (typically <38°C or 100.4°F)
Refusal of food due to gum discomfort
Mildly swollen or tender gums over erupting teeth
Otitis Media: Moderate to high fever (often >38.5°C or 101.3°F)
Ear pulling or tugging
Increased crying and irritability, especially when lying down
Difficulty sleeping
Decreased appetite
Possible clear or purulent nasal discharge
Vomiting or diarrhea in some cases
Hearing difficulties (intermittent).
Signs:
Teething: Palpable raised areas on the gums corresponding to erupting teeth
Redness or swelling of the gums
Absence of other significant systemic symptoms or signs of infection
Otitis Media: Tympanic membrane may appear red, bulging, opaque, and may have diminished mobility
Fluid (effusion) may be visible behind the eardrum
Decreased light reflex
Possible tympanic membrane perforation with otorrhea.
Diagnostic Criteria:
Diagnosis of teething is primarily clinical, based on age, history, and physical examination of the gums, in the absence of signs of infection
Otitis media diagnosis typically relies on the presence of acute symptoms of middle ear inflammation plus middle ear effusion, as evidenced by tympanic membrane characteristics (bulging, limited mobility, fever, recent onset of otorrhea, or intense ear pain).
Diagnostic Approach
History Taking:
Key history points: Age of the child
Onset and duration of symptoms
Fever (temperature, pattern)
Presence of ear pulling/tugging
Nasal congestion or discharge
Cough
Vomiting or diarrhea
Feeding patterns
Irritability level
Any recent upper respiratory infection
Red flags: High fever (>39°C), severe lethargy, difficulty breathing, stiff neck, dehydration, worsening ear pain despite initial treatment, discharge from the ear.
Physical Examination:
Systematic examination approach: Assess general appearance and activity level
Measure vital signs, including temperature
Inspect the oropharynx for signs of infection (e.g., erythema, exudates)
Carefully examine the ears using an otoscope, assessing the tympanic membrane characteristics (color, position, mobility, presence of fluid, perforation)
Palpate cervical lymph nodes
Auscultate lungs and heart.
Investigations:
Investigations are usually not required for suspected teething
For suspected otitis media, a diagnosis is primarily clinical
However, in complex cases or if a different diagnosis is suspected, investigations might include: Rapid strep test or throat culture if pharyngitis is suspected
Viral respiratory panel if significant respiratory symptoms are present
Blood work (CBC) is rarely indicated but may show leukocytosis in bacterial infections
Tympanometry can objectively assess middle ear pressure and eardrum compliance, useful in confirming effusion or assessing treatment response.
Differential Diagnosis:
Conditions to consider: Teething is a diagnosis of exclusion
Differential diagnoses for symptoms attributed to teething or OM include: Pharyngitis (viral or bacterial)
Viral upper respiratory infections
Tonsillitis
Adenoiditis
Cervical lymphadenitis
Mastoiditis (a complication of OM, presenting with postauricular swelling and tenderness)
External otitis (swimmer's ear)
Dental abscess
Meningitis (rare but critical to rule out with severe systemic symptoms).
Management
Initial Management:
For suspected teething: Reassure parents that teething is normal
Focus on symptomatic relief
Advise on safe teething remedies
For suspected otitis media: Assess severity and child's condition
Initiate appropriate pain and fever management
Consider antibiotics based on age, severity, and diagnostic certainty.
Medical Management:
Teething: Offer chilled teethers or clean fingers for chewing
Topical teething gels (e.g., containing benzocaine or lidocaine) should be used with caution and sparingly due to potential systemic absorption risks and toxicity, especially in young infants
acetaminophen or ibuprofen may be considered for discomfort if needed
Otitis Media: Pain relief: Acetaminophen (10-15 mg/kg/dose every 4-6 hours) or Ibuprofen (5-10 mg/kg/dose every 6-8 hours)
Antibiotics: Amoxicillin (80-90 mg/kg/day divided every 12 hours) is the first-line treatment for uncomplicated acute otitis media in children over 6 months
Alternative antibiotics include amoxicillin-clavulanate, cefdinir, cefuroxime, or azithromycin for specific indications or allergies
Duration of treatment is typically 7-10 days for children < 2 years or with severe symptoms, and 5-7 days for children ≥ 2 years with mild-moderate symptoms.
Surgical Management:
Surgical management is generally not indicated for simple teething or typical otitis media
Myringotomy with tympanostomy tube insertion may be considered for recurrent acute otitis media (≥3 episodes in 6 months or ≥4 episodes in 12 months) or persistent otitis media with effusion for more than 3 months causing hearing loss or other complications.
Supportive Care:
Teething: Offer fluids frequently
Monitor for signs of dehydration
Ensure safe sleep practices
Otitis Media: Ensure adequate hydration
Encourage rest
Monitor for worsening symptoms or development of complications
Follow-up with healthcare provider as recommended to assess treatment response.
Complications
Early Complications:
Teething: Generally none, though discomfort can lead to poor feeding and sleep
Otitis Media: Tympanic membrane perforation
Otorrhea (discharge from the ear)
Mastoiditis (infection of the mastoid bone)
Facial nerve palsy
Labyrinthitis
Meningitis or intracranial abscess (rare)
Sepsis.
Late Complications:
Teething: None
Otitis Media: Hearing loss (temporary due to effusion, or permanent due to scarring/cholesteatoma)
Chronic suppurative otitis media
Tympanosclerosis
Cholesteatoma formation.
Prevention Strategies:
Teething: None specific, it's a physiological process
Otitis Media: Encourage breastfeeding
Avoid exposure to tobacco smoke
Promptly treat viral upper respiratory infections
Vaccinations (pneumococcal, influenza)
Consider prophylactic antibiotics in specific high-risk children, though this practice is less common now due to concerns of resistance.
Prognosis
Factors Affecting Prognosis:
Teething: Excellent prognosis, symptoms resolve with tooth eruption
Otitis Media: Generally good with appropriate treatment, especially for uncomplicated cases
Factors influencing prognosis include age, severity of illness, presence of complications, and promptness of treatment
Recurrence is common.
Outcomes:
Teething: Resolution of symptoms once the tooth has fully erupted
Otitis Media: Most children recover fully with resolution of infection and effusion
Hearing typically returns to normal
Recurrent episodes may occur
Complicated OM or chronic effusion can lead to long-term sequelae.
Follow Up:
Teething: No specific follow-up required unless complications arise
Otitis Media: Follow-up within 24-48 hours if symptoms are severe or not improving
A re-evaluation visit typically 4-6 weeks after completion of antibiotic therapy is recommended to confirm resolution of effusion and assess hearing, especially in children < 2 years or with persistent symptoms.
Key Points
Exam Focus:
Differentiate low-grade fever/irritability of teething from moderate-high fever/ear pain of otitis media
Recognize key otoscopic findings in OM (bulging, red TM)
Understand first-line antibiotic choices and dosages for AOM
Know indications for tympanostomy tubes
Be aware of complications of untreated or recurrent OM.
Clinical Pearls:
Always consider otitis media in an infant presenting with fever and fussiness
A history of recent URI is a significant clue for OM
Gentle tugging at the ear can indicate ear pain
Tympanic membrane mobility assessment with pneumatic otoscopy is crucial for diagnosing effusion
If in doubt, err on the side of caution and investigate OM, especially with fever.
Common Mistakes:
Attributing all infant fussiness to teething without ruling out infection
Underestimating the severity of otitis media
Inappropriate antibiotic use (e.g., wrong dosage, duration, or indication)
Not performing adequate follow-up to ensure resolution of OM and effusion.