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.
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.
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.
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.
Viruses are the most common cause.
Bacteria causing otitis media include: strep pneumoniae, moraxella, haemophilus, mycoplasma (bullous myringitis), Group A strep
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
- 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
- Facial palsy – if the facial nerve is exposed in the middle ear, as is found in 5 – 10% of patients
- 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).
The discharge will be mucoid in consistency, as it arises from the middle ear mucosa.
A secondary OE might also be evident.
Swabs grow pseuodomonas and staph aureus.
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 is defined as an abnormal collection of skin within the middle ear cleft (middle ear space, antrum and mastoid).
Symptoms include a foul-smelling scanty discharge and a reduction in hearing. It is most often painless.
There is usually a small amount of whitish discharge or skin-like tissue overlying the tympanic membrane; especially superiorly and posteriorly.
Refer to ENT OPD, unless a complication is suspected; in which case the patient should be seen acutely.
- Complications include:
- Loss of hearing – maybe complete
- Facial palsy
- Temporal lobe abscess
- Sigmoid sinus thrombosis
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).
- Ear or retroauricular pain
- Fever (often)
- Otorrhoea in 16-36%
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.
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.
Usually causes by strep pneumoniae, strep pyogenes, or pseudomonas.
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.
- Subperiosteal abscess
- Facial nerve palsy
- Sigmoid sinus thrombosis
- Epidural abscess
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.
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.