The ear

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14.1 The ear

Stuart Lewena, Gervase Chaney

1 Otitis externa usually results from excessive exposure to heat and moisture and is usually very painful. Treatment involves cleaning, keeping dry and topical antibiotics.

2 Acute otitis media is a very common emergency presentation, but not all red ear drums are due to otitis media. Management with adequate analgesia is essential. However, antibiotic use should be restricted to specific circumstances.

3 Discharging otitis media due to chronic suppurative otitis media usually presents with painless and offensive discharge. Treatment is with ear toilet and topical antibiotics. Oral antibiotics have little or no role.

4 Otitis media with effusion is very common in children, but treatment is unnecessary in the majority, with resolution over 3 months.

5 Mastoiditis continues to be a problem in the antibiotic era and in many cases is the first presentation of ear disease. Admission, myringotomy and IV antibiotics constitute the mainstays of medical management.

6 Ear trauma is uncommon. Accidental ear injuries are usually unilateral and isolated. Ear trauma is rare in the first year of life and may indicate non-accidental injury. Haematomas should be removed by aspiration or excision.

Otitis externa

Introduction

Otitis externa includes various conditions from the most common acute diffuse otitis externa (swimmer’s or tropical ear) to otomycosis, localised (furunculosis) or chronic otitis externa. It occurs commonly in hot, humid climates or in the summer of temperate climates. Risk factors also include swimming and other water exposure, local trauma, loss of the protective coating of the ear canal, including cerumen and obstruction of the ear canal. Allergy may also play a role.

History

It may initially present with aural fullness or itch, but usually progresses to pain with or without discharge. The pain is often severe and is worse with chewing.

Otomycosis or fungal otitis externa makes up 10% of cases and has a more insidious onset.

Examination

Oedema and erythema of the canal with serous or purulent discharge is usual. The tragus is tender to manipulation. With increased severity, the canal becomes occluded with periauricular oedema and may progress to otitis externa with cellulitis when the child becomes febrile with a toxic appearance.

Differentiation from acute otitis media with perforation or chronic suppurative otitis media is important. Usually in these conditions, the tragus and canal are not tender and there is no erythema and oedema of the canal.

Acute localised otitis externa (furunculosis) occurs in the posterosuperior aspect on the ear canal. Otomycosis has only mild canal wall inflammation and thick otorrhoea.

Investigations

Investigations are largely unnecessary and rarely alter empiric treatment. The organisms found in diffuse otitis externa are most commonly Pseudomonas aeruginosa and Staphylococcus aureus. Furunculosis is usually S. aureus and otomycosis – Aspergillus or Candida species. Consideration of cultures – aerobic, anaerobic and fungal – is worthwhile in cases resistant to routine therapy or if there is more extensive disease – such as associated cellulitis.

Treatment

Acute diffuse otitis externa is managed with frequent gentle cleaning of the canal, along with avoidance of water (swimming prohibited). Ototopical medications are the mainstay of treatment, usually topical antibiotics such as framycetin/gramicidin/dexamethasone combinations. Ciprofloxacin is also effective. Insertion of a wick or ribbon gauze is also helpful. Close follow up for repeated cleaning with or without wick reinsertion may be required.

Furunculosis treatment is by local heat application and oral antibiotics (flucloxacillin or cephalexin) or incision and drainage. Otomycosis will require canal cleaning and antifungal drops or gentian violet.

Prevention

Keeping the ear canal dry and avoidance of trauma to the canal are the mainstays of prevention.

Complications

Progression to cellulitis of the nearby skin/soft tissue and/or lymphadenitis may occur. Oral antibiotics are usually then indicated, with cephalexin a reasonable first choice, but antipseudomonal antibiotics may be necessary. Progressive cellulitis and a toxic-appearing child will require admission for intravenous antibiotics, including pseudomonas cover. Less commonly, involvement of the parotid gland, temporomandibular joint or base of skull may occur.

Chronic otitis externa may occur, and may be a sign of an underlying dermatological disease such as seborrhoeic or atopic dermatitis.

Acute otitis media

Introduction

Acute otitis media (AOM) is one of the most common primary care paediatric presentations. It occurs as a result of infection of the middle ear cavity by both viral and bacterial organisms. It is frequently over diagnosed and remains a common cause for excessive antibiotic use. Adequate analgesia and a selective approach to antibiotic use are the mainstays of management.

History

Classic symptoms include fever, malaise and ear pain. The pain can be severe and during the night may wake the child. Other systemic features such as nausea and vomiting can occur. In younger children, presentation is often non-specific, with crying and irritability. Eardrum perforation and otorrhoea may occur (see complications). These symptoms may present as a primary complaint or frequently occur in the course of an upper respiratory infection.

Examination

A red, bulging, non-mobile tympanic membrane is the most reliable constellation of signs. Redness of the eardrum is a non-specific finding and may be seen with a high fever or following crying. Alone, therefore, it is not diagnostic of otitis media and is an inadequate finding to make the diagnosis.

Investigations

The diagnosis of otitis media is made solely on clinical grounds and investigations are rarely performed. In cases where tympanostomy has been performed, two-thirds are bacterial-culture positive, with a predominance of Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae.

Treatment

The administration of adequate analgesia is paramount to the management of acute otitis media. Paracetamol alone may not be adequate and the combination with codeine may be required. Topical instillation of lidocaine 2% has been shown to be a useful adjunct for rapid pain control but should be combined with longer-acting oral analgesia. Decongestants and antihistamines have not been shown to be effective and are not recommended.

The majority of cases of otitis media will resolve spontaneously. However, antibiotics continue to be widely used. In an otherwise healthy child over 2 years, most authorities now recommend deferring antibiotic use for 2 to 3 days, and to commence treatment only if the child remains symptomatic at review. Approximately 80% of children will avoid antibiotic use with this approach. Provision of a prescription upfront, with advice to commence antibiotics in 2 to 3 days if the child remains unwell, has been shown to result in approximately 50% of children avoiding antibiotics. Both strategies are reasonable, with the latter chosen in cases where access to timely medical review is uncertain. Early antibiotic therapy continues to be advocated in the very young or those with comorbidity.

Amoxicillin is a reasonable first-line antibiotic choice. The usual recommended dose is 45 to 90 mg kg⁻¹ per day. Amoxicillin + clavulanate is the next choice for poor responders. Cefaclor has a significant rate of serum sickness reactions in children and should not be used.

Topical otic antibiotic preparations may be used instead of oral antibiotics in cases with tympanic membrane perforation or those with intact tympanostomy tubes when purulent otorrhoea is the prominent finding.

Complications

The most common complication is perforation of the drum and otorrhoea. Other complications are very unusual but potentially severe. Most are due to bacterial spread and include extracranial complications such as mastoiditis, cholesteatoma and facial nerve paralysis and intracranial complications such as epidural abscess, meningitis and lateral sinus thrombosis.

Persistent middle ear effusions are almost universal after an episode of acute otitis media and should not be viewed as a complication. Complete resolution over several months occurs in 90% of cases.

Prevention

Prophylactic antibiotics confer a small decrease in recurrence at best, and are likely to contribute to increasing antibiotic resistance and generally are not recommended. More appropriate means of reducing recurrence include avoidance of passive smoke exposure, reducing day-care attendance and immunisation (pneumococcal and influenza).

Discharging otitis media – chronic suppurative otitis media

Introduction

Persistently discharging otitis media is most common in developing countries and certain high-risk populations in developed nations, such as Aboriginal Australians. It generally occurs following perforation of the eardrum from acute otitis media. It may also occur as a complication of tympanostomy tube (grommet) placement.

History

There is usually an absence of pain and a variable history (often weeks) of discharge that is purulent and offensive. It is often recurrent.

Examination

The canal is usually non-tender and there is usually no inflammation or some chronic inflammation. If the tympanic membrane can be visualised, usually only after ear toilet, there will be a perforation or tympanostomy tube in situ.

Investigations

Investigations are largely unnecessary. If performed, the organisms found on ear swabs are most commonly Pseudomonas aeruginosa and Staphylococcus aureus.

Treatment

Ear toilet (using a dry tissue spear) and topical antibiotics, particularly quinolones (such as ciprofloxacin with hydrocortisone) or framycetin/gramicidin/dexamethasone combinations, have been demonstrated to be effective in acute resolution of otorrhoea. Long-term outcomes are still to be determined. Systemic antibiotics alone are not as effective and addition to topical treatment does not improve outcome.

Complications

Chronic perforation and discharge are the main issues, although hearing impairment may be a problem. Cholesteatoma occurs in a small proportion of affected children.

Otitis media with effusion

Introduction

Otitis media with effusion (OME) is the presence of a middle-ear effusion in the absence of acute inflammation. It is unlikely to be a presenting complaint in an emergency department (ED) setting. It is more likely to be an incidental finding. It is extremely common, particularly in pre-school children. Its significance is in relation to its effect on conductive hearing.

History

Older children may present with aural fullness or reduced hearing. OME is usually asymptomatic in young children.

Examination

The eardrum may appear dull and non-erythematous and the effusion is most easily recognised by the presence of bubbles or a fluid level. If these are not present, pneumatic otoscopy will demonstrate impaired mobility.

Investigations

No acute investigations are indicated. In persistent cases, referral for audiology is recommended to determine any significant hearing loss.

Treatment

As the majority of OME cases will resolve spontaneously (90% by 3 months) a period of observation is recommended. Persistent OME is more likely to follow acute otitis media in the first year of life.

Trials of many different treatments including antibiotics, nasal decongestants, nasal insufflation, and corticosteroids have failed to show benefit. Persistent OME with concerns of significant hearing loss is an indication for audiology and referral to an ear, nose and throat (ENT) surgeon for consideration of tympanostomy tubes (grommets).

Complications

The principal concern for persistent OME is conductive hearing loss and potential impact on language and cognitive development. There are potential long-term changes to the tympanic membrane and middle ear that may cause hearing loss (e.g. tympanosclerosis).

Mastoiditis

Introduction

Mastoiditis is the infection of the mastoid air cells. It is an infrequent illness with a rate of between 1.2 and 4.2 per 100 000 person years in developed nations. Presentation can occur at any age, with a median of 12–48 months. There is some evidence that decreased use of antibiotics for AOM has resulted in a small increase in cases of mastoiditis. However, it is estimated that approximately 5000 children with otitis media would need to be treated with antibiotics to prevent 1 case of mastoiditis.

History

Symptoms at presentation with mastoiditis are very similar to AOM, with pain, irritability and fever. Mean time from onset of illness to signs of acute mastoiditis has been reported as just over 4 days.

Examination

Examination findings differentiating mastoiditis from AOM include protrusion/displacement of the auricle, post-auricular inflammation and tenderness, and narrowing of the external auditory canal. The tympanic membrane is usually abnormal and may be perforated.

Investigations

Increased routine use of computerised tomography scanning is due to the difficulty in diagnosis of subperiosteal abscess by clinical examination alone. Magnetic resonance imaging may also be valuable. Bacteriological diagnosis can be made at the time of operative treatment. Cultures show Streptococcus pneumoniae, Strep. pyogenes and Staph. aureus to predominate but many organisms are possible. P. aeruginosa can be seen in chronic or recurrent cases.

Treatment

Management has historically been cortical mastoidectomy. However, a number of series report successful treatment in the majority of cases with myringotomy and intravenous antibiotics. Broad-spectrum antibiotics such as third-generation cephalosporins are generally recommended, although antipseudomonal antibiotics may be required.

Complications

Complication rates are significant (13–35%) and include subperiosteal abscess, facial nerve paralysis, sigmoid sinus thrombosis, epidural abscess and meningitis.

Trauma

Introduction

Paediatric ear trauma is an uncommon presentation to an ED. Accidental ear trauma is almost always unilateral. There is the usual male predominance, with a majority between 1 and 7 years of age. Accidental ear trauma is rare in the first year of life and such presentations should be assessed for possible non-accidental (inflicted) injury. Other suggestive findings are bilateral ear injuries and associated injuries, particularly retinal haemorrhages and subdural haematoma.

History and examination

The most common mechanism is falls, followed by blows from an object and self-inflicted penetrating injuries which may result in perforation of the tympanic membrane. The most common objects inserted are cotton buds. Dog bites of the ear also occur. Lacerations are the most common injury, followed by bruising, abrasions and haematomas. Blood in the canal is a common finding in the penetrating injuries, making assessment of the eardrum difficult at the time of initial presentation. Burns are rare and are likely to be associated with more extensive burns. Barotrauma from explosions and loud noises are uncommon compared to industrial injuries in adults.

Assessment should include assessment of the facial nerve and hearing.

Investigation

Acute investigations are rarely required. However, audiology and ENT referral is indicated in penetrating and barotrauma injuries.

Treatment

Minor lacerations may be managed with steristrips, glue or suturing under local anaesthesia. Complex or larger lacerations will often require a general anaesthetic and surgical repair. Haematomas can lead to cartilage necrosis, infection and chondritis or fibrous organisation. All of these have potential to cause significant deformity. Therefore removal of the haematoma is indicated. Smaller haematomas can be aspirated and larger or recurrent collections should be evacuated. Appropriate contoured pressure dressings are then required to avoid reaccumulation. Penetrating injuries will often require ENT referral. Unless minor, burns will require evaluation by a burns specialist.

Complications

The main concerns are cosmetic deformity from haematomas, lacerations and burns, and hearing loss from penetrating injuries.

Controversies and future directions

Acute otitis media:

• Antibiotic usage for acute otitis media in Australia, the UK and USA remains high. Due to concerns over the emergence of antibiotic resistance, the Netherlands has limited antibiotic use (31%), with good results leading to a review of use in high-prescribing countries. The concern about lower rates of antibiotic use is the potential for increased complications (see mastoiditis).

Discharging otitis media – chronic suppurative otitis media:

• Concern has arisen with the use of potentially ototoxic antibiotic ear drops in the presence of a tympanic-membrane perforation, despite routine use by ENT specialists with few reported cases of ototoxicity.

• A series of nine cases of iatrogenic topical vestibulotoxicity, all secondary to gentamicin-containing eardrops, has been reported. As a result, agents such as ciprofloxacin are being increasingly used.

Otitis media with effusion

• Ventilation-tube (grommet) insertion remains one of the most common surgical procedures performed in children.

• It is effective at improving hearing in the short term. There has been conflicting evidence for its long-term benefit on language and cognitive development.

Further reading

Acuin J. Extracts from ‘concise Clinical evidence’: Chronic suppurative otitis media. Br Med J. 2002;325(7373):16.

Acuin J., Smith A., Mackenzie I. Interventions for chronic suppurative otitis media. Cochrane Database Syst Rev. 2, 2000. John Wiley & Sons, Chichester

Ah-Tye C., Paradise J.L., Colborn D.K. Otorrhea in young children after tympanostomy-tube placement for persistent middle-ear effusion: Prevalence, incidence, duration. Paediatrics. 2001;107(6):1251-1258. [comment]

Bitar C.N., Kluka E.A., Steele R.W. Mastoiditis in children. Clin Paediatr. 1996;35(8):391-395.

Bolt P., Barnett P., Babl F.E., Sharwood L.N., et al. Topical lignocaine for pain relief in acute otitis media: results of a double-blind placebo-controlled randomized trial. Arch Dis Child. 2008;93(1):40-44.

Brook I. Treatment of otitis externa in children. Paediatr Drugs. 1999;1(4):283-289.

Butler C.C., Van Der Voort J.H. Oral or topical nasal steroids for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev 2002, 4. 2000. [update ofCochrane Database of Syst Rev4:CD001935, PMID: 11034736].

Byington C.L. The diagnosis and management of otitis media with effusion. Paediatr Ann. 1998;27(2):96-100.

Cantor R.M. Otitis externa and otitis media. A new look at old problems. Emerg Med Clin N Am. 1995;13(2):445-455.

Cohen-Kerem R., Uri N., Rennert H., et al. Acute mastoiditis in children: Is surgical treatment necessary? J Laryngol Otol. 1999;113(12):1081-1085.

Combs J.T. Diagnostic accuracy of otitis media. Paediatrics. 2003;112(1):205-206.

Dagan R., McCracken G.H.Jr. Flaws in design and conduct of clinical trials in acute otitis media. Paediatr Infecti Dis J. 2002;21(10):894-902. [comment]

Del Mar C.B., Glasziou P.P. Should we now hold back from initially prescribing antibiotics for acute otitis media? J Paediatr Child Health. 1999;35(1):9-10.

Dowell S.F., Marcy S.M., Phillips W.R., et al. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Paediatrics. 1998;101(1):163-165.

Dowell S.F., Marcy S.M., Phillips W.R., et al. Otitis media – Principles of judicious use of antimicrobial agents. Paediatrics. 1998;101(1):165-171.

Flynn C.A., Griffin G., Tudiver F. Decongestants and antihistamines for acute otitis media in children. Cochrane Database of Syst Rev 2002, 1. 2001. [update ofCochrane Database Syst Rev2:CD001727, PMID: 11406002].

Froom J., Culpepper L., Green L.A., et al. Antimicrobials for acute otitis media? A review from the international primary care network. Br Med J. 1997;315(7100):98-102.

Garbutt J., Jeffe D.B., Shackelford P. Diagnosis and treatment of acute otitis media: An assessment. Paediatrics. 2003;112(1):143-149.

Glasziou P.P., Hayem M., Del Mar C.B., et al. Antibiotics for acute otitis media in children. Cochrane Database Syste Rev 2000, 4. 2000. [update ofCochrane Database Syst Rev2:CD000219, PMID: 10796513].

Holmes R.E. Management of traumatic auricular injuries in children. Paediatr Ann. 1999;28(6):391-395.

Hughes E., Lee J.H. Otitis externa. Paediatr Rev. 2001;6:191-197.

Kozyrskyj A.L., Hildes-Ripstein G.E., Longstaffe S.E., et al. Short course antibiotics for acute otitis media. Cochrane Database Syst Rev. 2, 2000.

Little P., Gould C., Williamson I., et al. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. Br Med J. 2001;322(7282):336-342.

Little P., McCormick D.P., Chonmaitree T., et al. Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: Pragmatic randomised trial. Br Med J. 2002;325(7354):22. [commentary: research directions for treatment for acute otitis media]

Pond F., McCarty D., O’Leary S. Randomized trial on the treatment of oedematous acute otitis externa using ear wicks or ribbon gauze: Clinical outcome and cost. J Laryngol Otol. 2002;116(6):415-419.

Rovers M.M., Straatman H., Ingels K., et al. The effect of ventilation tubes on language development in infants with otitis media with effusion: A randomized trial. Paediatrics. 2000;106(3):e42.

Rovers M.M., Straatman H., Ingels K., et al. Randomised controlled trial of the effect of ventilation tubes (grommets) on quality of life at age 1–2 years. Arch Dis Child. 2001;84(1):45-49. [comment]

Ruohola A., Heikkinen T., Meurman O., et al. Antibiotic treatment of acute otorrhea through tympanostomy tube: Randomized double-blind placebo-controlled study with daily follow-up. Paediatrics. 2003;111(5–1):1061-1067.

Segal S., Eviatar E., Lapinsky J., et al. Inner ear damage in children due to noise exposure from toy cap pistols and firecrackers: A retrospective review of 53 cases. Noise & Health. 2003;5(18):13-18.

Spratley J., et al. Acute mastoiditis in children: Review of the current status. Int J Pediatr Otorhinolaryngol. 2000;56(1):33-40.

Steele B.D., Brennan P.O. A prospective survey of patients with presumed accidental ear injury presenting to a paediatric accident and emergency department. Emerg Med J. 2002;19(3):226-228.

Straetemans M., Sanders E.A., Veenhoven R.H., et al. Pneumococcal vaccines for preventing otitis media. Cochrane Database Syst Rev. 2, 2002.

Thompson P.L., Gilbert R.E., Long P.F., et al. Effect of antibiotics for otitis media on mastoiditis in children: a retrospective cohort study using the Unitied Kingdom general practice research database. Pediatrics. 2009;123(2):424-430.

Van Zuijlen D.A., Schilder A.G., Van Balen F.A., Hoes A.W., et al. National differences in incidence of acute mastoiditis: Relationship to prescribing patterns of antibiotics for acute otitis media? Paediatr Infect Dis J. 2001;20(2):140-144. [comment]

Vassbotn F.S., Klausen O.G., Lind O., Moller P., et al. Acute mastoiditis in a Norwegian population: A 20 year retrospective study. Int J Paediatr Otorhinolaryngol. 2002;62(3):237-242.

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