He’s always sick: ENT infections and immunodeficiency

Cite this article as:
Alasdair Munro. He’s always sick: ENT infections and immunodeficiency, Don't Forget the Bubbles, 2019. Available at:

Otis is a 3yr old boy presenting to the emergency department with fever, and purulent discharge from his left ear. He otherwise looks well, however, his mother mentions this is his third ear infection since he was born, and he always seems to have a cough and a cold. She asks you if there could be a problem with his immune system?

Some children seem to have constant ear, nose or throat infections during childhood. We know that for a small, but important minority of children this may be the presenting feature of a primary immunodeficiency. Let’s look at how these may present, when to think of it, and what to do about it.

Primary immunodeficiency is rare

It’s worth stating from the outset, that the majority of children with recurrent ENT infections will not have a primary immunodeficiency. There is a relatively common phenomenon called “physiological immunodeficiency of infancy”, where-by there is a natural nadir in immunoglobulin levels as maternal immunoglobulin fades, and the child’s own immune system has only just become able to produce immunoglobulin for itself. This is at its lowest between 3-6 months and normally resolves by age 1. However, fully developed protection against encapsulated organisms doesn’t reach maturity until between 2-5 years, and IgA production doesn’t reach adult levels until adolescence. It can be completely normal for young children to suffer 4-11 respiratory infections a year (depending on exposure, e.g. siblings, nursery, etc.)

When should I suspect immunodeficiency?

When considering the characteristics of infections that should trigger suspicion for immunodeficiency, we should be thinking about:

More severe infections than is usual

Combined immunodeficiency disorders (affecting both cellular and humoral immunity), such as severe combined immunodeficiency (SCID), present in the first 3-6 months with severe, life-threatening infection. Unusually aggressive infections should prompt further investigation

Infections with unusual organisms

Infections with certain pathogens can point towards specific diagnoses, including respiratory infections with Pseudomonas aeruginosa (think cystic fibrosis or primary ciliary dyskinesia), oral/oesophageal candidiasis (think HIV or chronic granulomatous disease), upper respiratory infections with Pneumocystis carinii (think HIV or other T cell deficiencies) or recurrent otitis/sinusitis with Neisseria meningitidis (think complement deficiency).

Finally, to a lesser extent:

Frequency of infection

This is the least predictive of immunodeficiency, given the discussion above. Very frequent sinopulmonary infections in younger children with encapsulated bacteria can be the presenting feature of the rare condition X-linked agammaglobulinaemia (XLA: boys who produce no immunoglobulins). In late childhood and adolescence, the same presentation in a milder form may be a sign of combined, variable immunodeficiency (CVID), which is a heterogeneous group of disorders of antibody production.

Other, rare conditions include chronic granulomatous disease (CGD) which may present with deep abscesses of the outer ear or mastoid, or HIV presenting with recurrent otitis media (normally with other associated features)


When to refer

Some general guidelines have been produced by the Jeffrey Modell foundation for when to consider referral for immunodeficiency workup:

  • Four of more new ear infections within 1 year
  • Two or more serious sinus infections within 1 year
  • Two or more months on antibiotics with little effect
  • Two or more pneumonias within 1 year
  • Failure of an infant to gain weight or grow properly
  • Recurrent, deep skin or organ abscesses
  • Persistent thrush in the mouth or fungal infection on skin
  • Need for intravenous antibiotics to clear infections
  • Two or more deep-seated infections including septicaemia
  • A family history of primary immunodeficiency

Although having a low specificity, they provide a useful framework when thinking of children with more severe infections than usual.


Should I do some tests?

If considering referral, there are definitely some basic tests are useful to do first (if the child is severely unwell, don’t wait for tests to refer).

Full blood count

This is useful for ANY suspected immunodeficiency. Persistent lymphopaenia in a child <2yrs should prompt screening for SCID.

NB: It can be normal to have transient lymphopaenia or neutropaenia in isolation in young children following a viral illness. Incidental neutropaenia does not need repeat testing if there are no concerns about underlying immunodeficiency.


IgG, IgM and IgA levels are useful to investigate children with recurrent ENT/airway infections.

It is also worth considering an HIV test if symptoms are consistent, but ensure you have a discussion with parents before testing.

If both FBC and immunoglobulins are normal in the setting of recurrent infections, it is perfectly acceptable to wait for 3 -6 months to see if the condition improves before referral.



  • Primary immunodeficiencies are rare but important, and ENT infections may be the presenting feature
  • The severity of infection and presence of opportunistic pathogens are a much stronger predictor than the frequency of infections
  • Basic tests such as FBC and Immunoglobulins should be performed in children prior to/pending referral if they are not severely unwell
  • Consider investigation and referral for primary immunodeficiency early in children with severe infections and failure to thrive, or those with family history

Further reading: https://www.entmasterclass.com/ENT_Journal_2019_Interactive.pdf page 9

Respiratory Tract Infections in children

Cite this article as:
Patel,S and Munro, A. Respiratory Tract Infections in children, Don't Forget the Bubbles, 2019. Available at:

Emily is a 2 year old girl brought to the emergency department with her mum, following two days of fever and poor intake. She has a temperature of 39°C and looks a little unhappy, but has no red flags for sepsis. On examination of her throat you see she has enlarged, red tonsils bilaterally with exudate. Her examination is otherwise normal. Should you prescribe her antibiotics?

Ears looking at you, kid

Cite this article as:
Andrew Tagg. Ears looking at you, kid, Don't Forget the Bubbles, 2016. Available at:

Earache is a leading cause of grumpiness in children.  A recent paper in the New England Journal of Medicine has suggested that a 10 day course of antibiotics is more effective than a 5 day course in treating acute otitis media and, as such, should be considered in infants under 2 years with otitis media. But is this right?

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:

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.


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.


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.


  • 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.


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.


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


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


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.


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.

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


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
  • Vertigo/nystagmus
  • Facial palsy
  • Meningitis
  • 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)
  • 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.


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.


These include:

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


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.

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.


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:

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


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?


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




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



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




Bacteraemia occurs in 3%.



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.



Best Bets – Otitis Media

Hawke Library – otitis media guide


Otitis externa

Cite this article as:
Sinéad Davis. Otitis externa, Don't Forget the Bubbles, 2013. Available at:

A 7-year-old boy is brought to the ED by mum. He has ear pain (otalgia), reduction in his hearing and a little discharge from the ear. His symptoms have been getting worse over the last couple of days and now he is in a lot of pain despite analgesia, given by the parents. Mum thinks the infections might have started after he began his swimming lessons, 3 months ago.

 Is this history suggestive of otitis externa (OE) or acute otitis media (AOM)?

Bottom Line

  • Scanty white/yellowish discharge associated with an oedematous ear canal is otitis externa.
  • Pain often builds up over a couple of days and is increased on moving the pinna or pressing on the tragus.
  • Increased risk with exposure to water e.g. recent holidays, swimming lessons.
  • Treatment is with TOPICAL antibiotics (usually drops) and regular analgesia.

What is otitis externa?

It is acute inflammation and infection of the skin of the external auditory canal.

It might be localized, like a pimple, or more often is diffuse, involving all the skin of the ear canal. It might extend to involve the pinna, causing perichondritis, or infection of the side of the face, cellulitis or erysipelas.

from Hawke Library

Who gets it?

This condition is less common in children than acute otitis media, but certain conditions can predispose an individual to get this condition including:

  • Eczema, involving the skin of/near the ear
  • Psoriasis
  • Water exposure: recent holidays, regular swimming, frequent baths
  • Trauma, particularly from cleaning ears with cotton buds
  • Immunocompromised patients

What are the most common pathogens?

Otitis externa might be caused by bacterial, fungal, or viral infections.

Bacterial causes: Staphylococcus aureus, Pseudomonas aeruginosa
Fungal causes: Candida spp; Aspergillus niger
Viral causes: Varicella zoster; Herpes simplex

What are the clinical findings?

Patients will find it painful when you touch the pinna or if you push on the tragus. The ear canal is swollen and oedematous, to the point that it closes up in severe cases. White debris or yellowish discharge can be seen in the ear canal.

Signs of mucous, however, indicate a discharge from the mucosa in the middle ear, indicating a tympanic membrane perforation is present. In this case, the patient should be treated for AOM.

The patient will have reduced hearing. As the ear canal closes over from the swelling a conductive hearing loss develops.

from Hawke Library

How should I treat it?

If you can see into the ear canal, enough to see the discharge, then firstly treat with

TOPICAL antimicrobial agents: antiseptic  e.g acetic acid drops/spray, antibiotic e.g. aminoglycoside or fluoroquinolones (ciprofloxacin) drops

Steroids: topical – usually combined with the above drops.

Analgesia: this is a very painful condition – paracetamol/NSAIDS

If the canal is closed over, refer the patient to ENT for further management. This is likely to include micro-suction clearance of the ear canal debris and/or insertion of a dressing (wick) into the ear, onto which antimicrobial therapy can be instilled.

Side effects of the treatment

Aminoglycosides carry a risk of ototoxicity: the use of these agents is not advised if it is known that there is a tympanic membrane perforation.

Aminoglycosides, especially neomycin, can cause contact dermatitis in 15% of patients.

License for use of fluoroquinolone

Though the use of topical ciprofloxacin in the ear canal is licensed in the US and many countries worldwide, it is not licensed for this use in the UK. Despite this many clinicians, in the UK, will choose to prescribe this medication ‘off license‘; but in doing so should follow the published guidance of the General Medical Council, UK.

What are the other possible diagnoses?

In children, the most likely diagnosis is going to be AOM, with a TM perforation, so that the ear discharge has caused a secondary OE. In this case, the discharge will be mucoid (stringy) in consistency.

Selected references

Kaushik V, Malik T, Saeed S R. Interventions to treat acute otitis externa. Cochrane Database Syst Rev 2010;(1):CD004740

Marais J, Rutka J A. Ototoxicity and topical eardrops. Clin Otolaryngol Allied Sci 1998;23:360-367

GMC. Good practice in prescribing and managing medicines and devices.