ENT Part 1: a word in your ear

Cite this article as:
Tessa Davis. ENT Part 1: a word in your ear, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.7649

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.

Otitis media

Cite this article as:
James Miers. Otitis media, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3131

A 2-year-old presents to ED with pyrexia – he’s pulling at his ear constantly in the waiting room.  You know where this heading, but are you supposed to treat him with antibiotics or not?

Do you know the difference between acute otitis media (AOM) and otitis media with effusion ?

 

Bottom Line

 

What is it?

Otitis media is a general term that has been used to describe multiple disorders of middle ear inflammation

Acute otitis media (AOM)

Otitis media with effusion (OME)

Chronic otitis media (COM)

Establishing the diagnosis is important as antibiotic treatment is not recommended for OME

The definition of acute otitis media requires three equally important components, which must all be present.

  1. Acute onset (<48 hours) of signs and symptoms
  2. Middle ear effusion (MEE)
  3. Signs and symptoms of middle ear inflammation (at least one of fever, otalgia, irritability in an infant; red tympanic not due to crying or fever)

The normal tympanic membrane

Who gets it?

There is considerable overlap between presenting signs and symptoms of upper respiratory illnesses and acute otitis media, especially in the preverbal child.

The peak incidence of otitis media is between 6 and 18 months of age. Neonatal acute otitis media is uncommon. Most effusions of the middle ear in this age are sterile and develop in the in utero environment.

Environmental insults, such as tobacco smoke, lack of breastfeeding, and exposure to children in daycare who frequently receive antibiotics, may lead to episodes that would not otherwise occur.

Prevention of the disease burden is possible through the use of newer vaccines such as the contemporary pneumococcal vaccine that includes protection from seven serotypes of Streptococcus pneumoniae.

What are the most common bugs?

Bacteria from the nasopharynx are the most common cause of acute otitis media and can be isolated from middle ear fluid in a majority of cases. The most common pathogens in the post-pneumococcal vaccine era are:

  • Nontypeable Haemophilus influenzae (56%)
  • S. pneumoniae (31%)
  • Moraxella catarrhalis
  • Mycoplasma may cause a bullous myringitis

Neonates may be affected by gram negative organisms and Staph aureus.

The role of viruses is unclear.

These data were obtained in the post-pneumococcal vaccine era and represent a change from before this vaccination program was initiated. Of importance is a major change in the increased prevalence of β-lactamase organisms such as M. catarrhalis (almost 100%) and non-typeable H. influenzae (35% to 40%).

 

What is otitis media with effusion (OME)?

OME usually follows an episode of acute otitis media, and both are processes of the same disease continuum. OME may persist for weeks to months after an episode of acute otitis media.

Close to 90% of episodes of OME  resolve spontaneously after an acute otitis media episode is diagnosed.

Guidelines recommend watchful waiting without the immediate use of antibiotics for children with uncomplicated otitis media with effusion.

Children with permanent hearing loss, craniofacial anomalies, or underlying speech delays may receive immediate antibiotics or have close outpatient follow-up by the primary care clinician.

 

Should I treat it?

Consensus guidelines strongly recommend the treatment of pain associated with acute otitis media.

Prescribing only an antibiotic for the treatment of acute otitis media is inappropriate care, as antibiotics are not analgesic medications.

The primary systemic analgesics and antipyretics used to treat acute otitis media are ibuprofen and paracetamol. In one randomized trial comparing ibuprofen, acetaminophen, and placebo, only ibuprofen was found to be superior to placebo.

Opioid medications may be used at night during the sleeping hours, although no studies have demonstrated the effectiveness of this medication class for the treatment of acute otitis media.

High-dose amoxicillin, 80 to 90 mg/kg PO per day divided into two daily doses for 5 to 7 days, is the first-line recommended antibiotic for the treatment of uncomplicated acute otitis media.

The higher dose achieves concentrations in the middle ear that exceed the minimum inhibitory concentration for highly resistant forms of S. pneumoniae, the most common bacteria found in acute otitis media.

M. catarrhalis and non-typeable H. influenzae, although the addition of clavulanic acid increases the likelihood of vomiting and diarrhoea.

IM ceftriaxone for three daily doses may be considered if children cannot tolerate oral medications. Children with a known allergy to the penicillin class may consider the use of a macrolide agent, such as azithromycin.

A 10-day course of antimicrobials has been recommended for decades without any evidence to support an exact duration of therapy. Shortened treatment regimens (5 to 7 days) may reduce resistance to antibiotics and reduce side effects by decreasing total drug exposure.

What is the evidence for treatment?

Two randomized double-blinded placebo-controlled trials of young children diagnosed with AOM

Hoberman et al, University of Pittsburgh

Tahtinen et al, Turku University Hospital in Turku, Finland

In children between 6 months and 2 years of age with certain AOM, the use of antibiotics result in faster recovery and less treatment failure (reduced by 42-62% in the severe group)

Although a majority of patients receiving placebo also recovered spontaneously (53% in Hoberman et al, 55% in Tahtinen et al.), a physician cannot predict at the onset of illness which patients will improve without antibiotics.

Even in patients with non-severe illness, antibiotics were associated with a decrease rate of treatment failure.

Summary of Treatment

Antibiotics are advised for:

  • All infants under 6 months
  • Age 6 months – 2 years with certain diagnosis or uncertain diagnosis and severe illness
  • Age 2 years and over with certain diagnosis and moderate/severe illness

Observation:

Age 6 months onwards with uncertain diagnosis and follow up assured observation without antibiotics is an option for mild illness (no systemic features) with re-evaluation at 48 hours & antibiotics if no improvement

Summary of Antibiotic Choice

  • Antibiotic in the studies was amoxicillin-clavulanate
  • 1st line treatment is high dose amoxicillin, due to reduced side effects & drug exposure
  • Whether amoxicillin alone will yield the same benefit is unclear, although in previous studies  80% were successfully treated with amoxicillin
  • In severe disease, amoxicillin-clavulanate is the preferred first line

 

What are the complications?

Perforation

As in the photo below, there can still be a perforation that does not heal within a few weeks.  This is considered to be a ‘natural myringotomy’ and usually heals well.  Only GP follow-up is needed.

 

Small perforation

A small tympanic perforation taken from the Hawke Library

 

Facial Palsy

The facial nerve descends over the posterior wall (mastoid) of the middle ear and can be affected by OM

 

 

Mastoiditis

The infection can extend into the mastoid (posterior to the middle ear).  It can cause bone destruction, brain abscess, meningitis, VI and VII nerve palsies, lateral venous sinus thrombosis.  It is very unlikely if the ear exam is normal as it is linked to OM.

A CT is advised along for IV antibiotics (usually ampicillin)

 

Acute mastoiditis

 

Cholesteatoma

Cystic cholesterol lesions are linked to chronic OM and can erode local structures.

 

Cholesteatoma

Sepsis

Bacteraemia occurs in 3%.

 

Deafness

Conductive deafness can follow a persistent effusion.

 

Resolution and Follow-Up

Fever and ear pain should be expected for 24 to 48 hours after an ED evaluation. If symptoms persist 72 hours after antibiotic therapy has been initiated, reevaluation is needed. Routine, scheduled visits are not recommended for uncomplicated acute otitis media if symptoms have resolved.

Improvement should be evident by 2-3 days. Treatment failure may indicate incorrect diagnosis, development of a complication or presence of a resistant organism. If the initial treatment was amoxicillin, change to amoxicillin/clavulanate.

All children should be reviewed by the local doctor at 2 weeks for the presence of a persistent effusion (glue ear) or healing of the tympanic membrane (if ruptured).

ENT consultation is advised for children with persistent hearing loss or speech delay, chronic effusion for more than 3 months, frequent episodes of otitis media or underlying pathologies such as cleft palate or adenoidal hypertrophy.

 

References

Best Bets – Otitis Media

Hawke Library – otitis media guide