ENT Part 1: a word in your ear

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Here is the first part in our three part ENT series looking at recognition and management of common paediatric ENT conditions.This series is based on a presentation by Rahul Santram , adapted by Tessa Davis, and checked by our resident ENT surgeon, Sinéad Davis.

Today, we start with the ear. Part 2 is on – the nose. Part 3 is on – the throat.

Otitis externa

This can be acute or chronic and is otherwise known as swimmer’s ear. It occurs commonly in hot humid climates or in the summer of temperate areas.

Risk factors for developing otitis externa include – water exposure, local trauma, lack of cerumen (acidic protection), obstruction of the canal, and allergy.

Symptoms

There is often a history of aural fullness. Patients can have pain, which can be severe and worse on mastication. Otorrhoea may be present. 10% of cases are fungal and here there is a more insidious onset, with mild wall inflammation and thick otorrhoea.

Exam findings

On examination, you can see oedema and erythema of canal. There may be serous or purulent discharge. The tragus is often tender to manipulation (helps differentiate from otitis media). Sometimes there is occlusion of canal and periauricular oedema with increasing severity. There can be lymphadenopathy. Furunculosis (localised otitis externa) can occur anywhere in the outer third of the ear canal where the hair-bearing skin is located.

Organisms

Most commonly pseudomonas and staph aureus. Staph is usually causative in furunculosis.

In otomycosis, the culprits usually are aspergillus and candida.

Consider aerobic, anaerobic and fungal cultures in cases resistant to conventional treatment, or if disease is extensive.

Treatment

  • Aural toilet
  • Avoid water
  • Ciproxin HC drops
  • Ear wick (to allow for drop delivery if the canal is too narrow to allow the drops to flow into the canal naturally)

Furunculosis requires treatment with local heat application plus flucloxacillin or cephalexin. It may need incision and drainage.

Otomycosis requires ear toilet plus anti-fungal drops. It needs treatment for considerably longer than bacterial infections – often up to 6 weeks.

Complications

These include:

  • Mastoiditis
  • Meningitis
  • Lymphadenitis
  • Parotid/TMJ/BOS may get infected

Chronic OE may indicate dermatitis as an underlying disorder


Acute otitis media

This is an acute infection of the middle ear space, which is usually preceded by an URTI.

Diagnosis is not straight forward and it is frequently overdiagnosed in the paediatric population.

It is caused by both viruses and bacteria.

Antibiotic use is debated and indiscriminate use has led to resistant strains of bacteria.

It most commonly occurs from 6 months to 3 years of age.

Risk factors include: attending daycare; bottle-fed; cigarette smoking family; families with a history of otitis media.

Symptoms

Infants and young children present with less specific signs and symptoms including ear pulling, irritability, fever, vomiting and diarrhoea, and loss of appetite.

In older kids you can ascertain if there is loss of hearing.

Examination findings

On otoscopy you find a red and bulging tympanic membrane, pus in the middles ear, and loss of light reflex.

A bulging TM is the most specific finding, as the build up of pus in the middle ear space is the main condition that causes a bulging TM. Decreased mobility of the tympanic membrane on pneumatic otoscopy (due to fluid in the middle ear) is also evident, but will be seen in the presence of glue ear also. Unless you are skilled at performing pneumatic otoscopy, a child in pain is not likely to tolerate this procedure and it is unlikely to help in your diagnosis.

from hawkelibrary.com

Organisms

Viruses are the most common cause.

Bacteria causing otitis media include: strep pneumoniae, moraxella, haemophilus, mycoplasma (bullous myringitis), Group A strep

Treatment

Amoxycillin is the first line treatment in a bacterial infection. Many will be viral aetiology and will not require antibiotics. There should be no treatment in the absence of pus. Even in bacterial infections, without complications, antibiotics are not required unless the infection fails to improve over 48-72 hours.

A macrolide can be used if the patient has a penicillin allergy. Follow-up should be by the GP in 48 hours

Complications

These include:

  • Hearing loss
  • Recurrent otitis media – if otitis media occurs in the first year of life, there is increased risk of recurrence
  • Perforation of the tympanic membrane and otorrhoea
  • Labrynthitis
  • Mastoiditis
  • Facial palsy – if the facial nerve is exposed in the middle ear, as is found in 5 – 10% of patients
  • Meningitis
  • Cerebral abscess
  • Venous sinus thrombosis

Middle ear effusion occurs in many cases of otitis media, with spontaneous gradual resolution within three months in 90% of cases.

Persistent effusion (over 3 months) requires a tympanogram (to look for flattening) and an ENT review.


Chronically discharging ear

This occurs in the presence of a perforation of the tympanic membrane, which has usually arisen when a perforation due to AOM fails to heal. Ongoing discharge, which fails to settle spontaneously within 72 hours and is not treated with antibiotics, might be one reason why this condition develops. In Australia, Aboriginal and Pacific Island kids are at greater risk.

It also can occur as a complication of a tympanostomy tube (2% short-term and up to 15% long-term grommets leave a permanent perforation after the grommet extrudes).

Examination findings

The discharge will be mucoid in consistency, as it arises from the middle ear mucosa.

A secondary OE might also be evident.

Investigations

Swabs grow pseuodomonas and staph aureus.

Treatment

Treatment is ear toilet and ciproxin HC drops for the ear canal infection, and also systemic antibiotics for the middle ear mucosal infection.

Differential diagnosis should include cholesteatoma. This is particularly the case in developing nations.


Cholesteatoma

Cholesteatoma is defined as an abnormal collection of skin within the middle ear cleft (middle ear space, antrum and mastoid).

Symptoms

Symptoms include a foul-smelling scanty discharge and a reduction in hearing. It is most often painless.

Examination findings

There is usually a small amount of whitish discharge or skin-like tissue overlying the tympanic membrane; especially superiorly and posteriorly.

from hawkelibrary.com

Treatment

Refer to ENT OPD, unless a complication is suspected; in which case the patient should be seen acutely.

Complications

  • Complications include:
  • Loss of hearing – maybe complete
  • Vertigo/nystagmus
  • Facial palsy
  • Meningitis
  • Temporal lobe abscess
  • Sigmoid sinus thrombosis

Mastoiditis

This is a serious complication of otitis media.

It is infection of the mastoid air cells. Spread is from the middle ear via the aditus ad antrum.

The rate is 1.2-1.4 per 100,000. Age at presentation is upwards of 2 months (median of 1 to 4 years of age).

Symptoms

  • Ear or retroauricular pain
  • Fever (often)
  • Irritability
  • Otorrhoea in 16-36%

Examination findings

Patients have protrusion of the ear. There is post-auricular redness, warmth, oedema and tenderness. Otoscopy shows ear canal narrowing. The tympanic membrane looks just like it looks in acute otitis media.

from hawkelibrary.com

A CT scan can be carried out, looking for a sub-periosteal collection, if there are signs of a complication. Usually patients are treated with IV antibiotics and only scanned if they fail to improve.

Organisms

Usually causes by strep pneumoniae, strep pyogenes, or pseudomonas.

Treatment

Treatment is with IV antibiotics (third generation cephalosporin plus a quinolone).

Patients may require grommets if the mastoiditis fails to settle with antibiotics. This isn’t something that is rushed into. This is because a grommet inserted in the presence of infection is likely to extrude more quickly than when there is no infection. So one might put grommets in at a later date, unless a cortical mastoidectomy is required, in which case a grommet will be inserted at the time of that op.

Cortical mastoidectomy can sometimes be necessary.

Complications

These include:

  • Subperiosteal abscess
  • Facial nerve palsy
  • Sigmoid sinus thrombosis
  • Epidural abscess
  • Meningitis

Trauma

This is uncommon in the paediatric population. If the patient is less than 12 months, consider non-accidental injury (look for other signs).

Trauma is usually unilateral and is more common in males.

It can present as lacerations, bruising, abrasions, and haematomas.

If there is blood in the canal, the tympanic membrane may be damaged.

Treatment

Minor lacerations can be steristripped, glued, or sutured.

Complex lacerations should be referred to ENT.

Haematomas can cause cartilage necrosis and require incision and drainage.


Foreign bodies

These are common in paediatrics. There are visualise via otoscopy. Removal from the lateral third of canal is easier than the medial two thirds, as the medial part is osseous, narrow, vascular and more sensitive – it often needs ENT.

Removal requirements

  • Good restraint
  • Good light source
  • Possibly sedation
  • Irrigation is simplest. but contraindicated if the tympanic membrane is ruptured.
  • Suction
  • Forceps – alligator, Hartmanns
  • Right angle hook

Remember that button batteries cause necrosis – remove them ASAP.

Insects can be killed with 2% lignocaine.

Complications

These include:

  • Trauma to canal
  • Tympanic membrane rupture
  • Otitis externa

Post-removal care is to use ciproxin HC drops and avoid water.

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About 

Tessa Davis is a paediatric emergency registrar from Glasgow and Sydney, but currently living in London. Tessa tries to spend time with her 3 kids in between shifts. @tessardavis | + Tessa Davis | Tessa’s DFTB posts

Author: Tessa Davis

Tessa Davis is a paediatric emergency registrar from Glasgow and Sydney, but currently living in London. Tessa tries to spend time with her 3 kids in between shifts. @tessardavis | + Tessa Davis | Tessa’s DFTB posts