Download Management of the Draining Ear

Management of the
in Children
Draining Ear
Ashley Schroeder, MD and David H. Darrow, MD, DDS
D
rainage from the ear, or otorrhea, is commonly encountered in pediatric practice and can present a diagnostic and therapeutic quandary to the pediatrician. Otorrhea may result from
many causes, including soiling of ears with tympanostomy tubes or tympanic membrane
perforations, otitis externa, cholesteatoma, and foreign bodies. Less common etiologies include cerebrospinal fluid otorrhea from congenital malformations or trauma, otitic candidiasis, and malignancy.
Although the diagnosis cannot always be established at the first visit, a general approach to the
draining ear is possible that permits timely elucidation of the etiology and appropriate management or
referral if necessary. In this article, we offer such an approach and discuss rational management strategies for the common causes of otorrhea in children.
Dr. Schroeder is a physician with the Department of Otolaryngology – Head & Neck Surgery, Portsmouth Naval Medical Center, Portsmouth, VA, and a commander in the United States Navy. Dr. Darrow is associate professor of otolaryngology and pediatrics, Eastern Virginia Medical School, and attending otolaryngologist, Children’s Hospital of The King’s
Daughters, both in Norfolk,VA.
Address reprint requests to: David H. Darrow, MD, DDS, Department of Otolaryngology – Head & Neck Surgery, Eastern Virginia Medical School, 825 Fairfax Avenue, Norfolk,VA 23507.
Dr.Darrow is on the Speakers’Bureau with Alcon Laboratories.Dr.Schroeder has no industry relationships to disclose.
PEDIATRIC ANNALS 33:12 | DECEMBER 2004
843
EDUCATIONAL OBJECTIVES
1. Describe the differential
diagnosis of and initial
management of the draining ear
in children.
2. List the indications for, and
efficacy of, topical, oral, and
intravenous therapy of otorrhea
in children.
3. Discuss those situations in
which a child with otorrhea
should be referred to an
otolaryngologist.
APPROACH TO THE DRAINING EAR
When evaluating a child with otorrhea, a thorough history of the chief
complaint and past otologic events often
suggests an etiology (Sidebar 1, see
page 846). Bilateral drainage occurs
most commonly with tympanostomy
tubes or tympanic membrane perforations (Figure 1, see page xxx) but may
also occur in unusual cases of otitis
externa (swimmer’s ear). A history of
swimming or upper respiratory infection
preceding the onset of otorrhea is common with tubes or tympanic membrane
perforation. Bilateral cholesteatoma is a
rare occurrence. Long-standing drainage
usually suggests a chronic middle ear
process such as cholesteatoma or granulation tissue.
Chronic drainage also may result
when common infectious agents are
inadequately treated topically or systemically; when yeast, fungi, or
mycobacteria are present; or when the
patient is unable to mount an appropriate immune response. Bloody drainage
usually suggests the presence of granulation tissue or trauma to the ear canal,
although severe otitis media also may
occasionally be associated with this
finding. Pain on palpation of the auricle
most commonly is associated with otitis
externa but may be present when prolonged drainage of any kind has caused
irritation of the external ear. Deep pain
may be associated with complications of
otitis media.
CAUSES OF OTORRHEA
Tympanostomy Tube Otorrhea
Tympanostomy tube otorrhea is the
most common type of otorrhea encountered, occurring at least once in up to
75% of patients within the first 12
Figure 1. External crusting frequently is associated with draining ears.
844
months after tubes are inserted.1 In a
recent meta-analysis of patients who
underwent tube insertion, otorrhea was
characterized as early (less than 2 weeks
after placement) in 16% and late in
26%, and recurrent in 7.4% and chronic
in 4%.2 Early tube otorrhea most commonly is associated with mucoid or
purulent effusions at surgery and far less
commonly with serous or absent effusion.3 It is more likely related to middle
ear conditions at surgery than to sterile
preparation of the ear canal.4-6
Post-tympanostomy tube otorrhea
may be reduced by the use of antibiotic
eardrops at the time of tube placement
and by saline irrigation of the middle ear
through the myringotomy at surgery.7,8
Bacterial biofilms have been implicated
as a possible etiology in cases of recurrent and chronic otorrhea.9
Usually seen during episodes of
acute upper respiratory infection, tube
otorrhea is precipitated by the usual otitis media organisms (Streptococcus
pneumoniae, Haemophilus influenzae,
Moraxella catarrhalis). However, within hours to days, Pseudomonas aeruginosa may become the predominant
organism.10 In children older than 3,
middle ear organisms are cultured less
commonly and Staphylococcus aureus
is found more frequently.11,12 In the
summer, when otorrhea may be associated with infection from external
sources, involvement of nasopharyngeal
pathogens is even less likely.11
In most cases, tube otorrhea is painless and resolves spontaneously within a
few days. In children 6 or younger treated with oral placebo and daily suctioning of the tube, about one-third resolved
by day 4.13 In more persistent or symptomatic cases, topical or systemic
antimicrobial therapy may be indicated.
When the drainage is bloody or fails
to clear after ototopical therapy, granulation tissue often is present at the edge
of the tube (Figure 2). This occurs in 5%
PEDIATRIC ANNALS 33:12 | DECEMBER 2004
to 14% of patients whose tubes have
been in less than 3 years, and the risk of
developing granulation increases with
tube longevity.14 Although granulation
usually is present on the lateral surface
of the eardrum, the tissue may also
occupy the middle ear or even the lumen
of the tube, rendering it ineffective.
The risk of otorrhea due to water
exposure in patients with tubes has been
addressed in a number of studies.15-19 In
vitro models of tubes exposed to water
suggest that pressures of 12.8 to 13.3 cm
H20 (equivalent to approximately 6 feet
of depth below the surface) are required
to push most types of water through the
lumen of a standard tube.19 Most authors
of in vivo studies have concluded that
patients who swim on the surface and do
not make deep dives have no increased
risk of otorrhea with water exposure.15-21
Factors that may increase the risk of
otorrhea due to water exposure include
large lumen tubes or tympanic membrane perforations, soapy water (which
decreases surface tension), lake water or
water known to be contaminated, and
swimming at depths below 2 to 6
feet.15,18-20 When these factors are present, the ear should be protected using
commercially available ear plugs. Moldable putty plugs must be gently placed
in the ear so as to avoid fragmenting the
material deep in the ear canal. During
periods of brief water exposure, cotton
coated with petroleum jelly may provide
adequate protection.
For those uncommon patients who
are highly susceptible to otorrhea, limited water exposure or use of water precautions may be recommended. Ototopical medications may be used after
swimming, although these medications
occasionally may cause discomfort
when used in a dry middle ear.
Otitis Externa
Otitis externa is an infection of the
external auditory canal most commonly
PEDIATRIC ANNALS 33:12 | DECEMBER 2004
Figure 2. Granulation tissue and debris surround a retained tympanostomy tube.
preceded by mechanical or chemical
damage to the normal protective barrier
created by the skin and cerumen. The
loss of protective films and secretions
leads to elevated pH and an environment
in which infecting organisms thrive. P.
aeruginosa and S. aureus are the most
common infecting organisms, although
cultures from the canal may demonstrate
Escherichia
coli,
streptococci,
Aspergilli, or Candida albicans. Chronic
or recurrent external otitis may result
from fungal infection or from skin conditions such as eczema, seborrhea, or
psoriasis. In cases of eczematous dermatitis of the ear canal, moist vesicle and
pustules are seen acutely and crusts and
scales form in ears affected chronically.
Although otorrhea is often present,
the hallmarks of external ear infections
are severe pain and a sense of fullness in
the affected ear. When the ear canal is
patent, cheesy debris due to desquamation may be found along the canal walls.
In severe cases, the tympanic membrane
may be obscured and associated postauricular swelling may be confused with
mastoiditis. However, association with
swimming or canal trauma, the absence
of high fever, and pain with movement
of the auricle are more typical of otitis
externa. Equivocal cases should be
referred for otolaryngologic evaluation.
Chronic Suppurative Otitis Media
(Without Cholesteatoma)
Chronic suppurative otitis media
(CSOM) is characterized by otorrhea
through a perforation of the tympanic
membrane. This disorder begins as a
mucosal disease of the middle ear and
mastoid due to soiling of the middle ear.
Suppurative otitis is considered chronic
after 6 weeks, when scarring, osteitis,
and bone destruction may be present.2224
In most cases, the drainage is painless; however, in the presence of bone
involvement, otorrhea may be associat-
845
SIDEBAR 1.
Questions to Determine the Etiology of Otorrhea
1.
2.
3.
4.
5.
Is the drainage unilateral or bilateral?
How long has the drainage been present?
Has there been any bloody drainage?
Does the ear hurt? If so, is the pain deep or confined to the external ear?
Is there a history of tympanostomy tubes or tympanic membrane
perforation?
6. Does the child have any known immune deficiencies?
ed with deep pain and a foul smell.
Advanced cases may involve intracranial complications.
The offending organisms in CSOM
are much the same as seen in otitis
externa, with P. aeruginosa being the
most common isolate. However, many
cultures demonstrate polymicrobial
infections including gram-negative
bacilli, Staphylococcus aureus, and
anaerobes.22,23,25 The presence of middle
ear granulation may also suggest infection by mycobacteria.26 Other uncommon causes of CSOM include tuberculosis, syphilis, histiocytosis, and rhabdomyosarcomas.24
Recent reports suggest that medical
management of CSOM is successful in
75% to 89% of patients.22,23,25,27 A 10- to
14-day course of systemic antibiotic
therapy is recommended, accompanied
by daily aural toilet using the otologic
microscope. However, in studies by
Kenna and colleagues, among children
who failed medical management, 36%
to 50% had occult cholesteatoma at the
time of surgery.22,27 These data suggest
that the success rate of medical management in patients with true CSOM is
actually higher. However, CSOM and
cholesteatoma may simply represent
two points on the spectrum of ear disease and, in refractory cases, the patient
should be examined meticulously by an
otolaryngologist for abnormal tissue
within or extruding from the middle ear.
846
Computer tomography scanning may be
useful in evaluating the extent of the soft
tissue disease and biopsy of this tissue
through the perforation can occasionally
be performed in the office setting if necessary for diagnosis. Once the diagnosis
is established, tympanomastoidectomy
is often necessary for complete removal
of the cholesteatoma or soft tissue and
improve ventilation.
Granular Myringitis
Granular myringitis is characterized
by clear or purulent otorrhea associated
with flat granulations on the surface of a
thickened but intact tympanic membrane. This disorder may be seen in
patients with otitis externa, or may present separately. Frequently, the etiology
cannot be established. Treatment consists of debridement of the ear and treatment of the granulations with caustic or
antiseptic agents, such as silver nitrate,
trichloroacetic acid, gentian violet, or
steroid preparations.
Acute Otitis Media
Not infrequently, acute otitis media
presents with an acute perforation and
otorrhea. The diagnosis can usually be
made based on a history of fever and
symptoms of upper respiratory infection
associated with severe otalgia that suddenly resolved when the ear began
draining purulent material. The perforation is usually quite small and generally
closes within a few days. As a result,
ototopical medications are generally far
less effective in managing such infections than are systemic agents. Patients
should be reevaluated once the drainage
has ceased to be certain that the perforation heals and the middle ear effusion
clears spontaneously.
Cholesteatoma
Cholesteatoma, more properly
termed “aural keratoma,” is the growth
of squamous epithelium in the middle
ear space. This condition is frequently
associated with otorrhea, but the
drainage is often mild, resulting in inadequate therapy and delayed referral. The
mass consists of a matrix of differentiated squamous epithelium that grows by
accumulation of desquamated material.
A layer of granulation tissue surrounding the keratoma elaborates enzymes
that cause the bony destruction seen in
ears with this disease.
Aural keratoma generally is classified
as either congenital or acquired. Congenital keratomas are thought to arise
from epithelial rests within the middle
ear. They are most frequently encountered as a white pearl in the anterosuperior quadrant behind an intact tympanic
membrane. Destruction of the eardrum
and otorrhea generally occur only in
advanced stages after the keratoma has
grown considerably. Acquired keratoma
may result from deep, chronic retractions of the tympanic membrane, usually
in the region of the pars flaccida (“primary acquired keratoma”), or from
chronic perforation of the tympanic
membrane resulting in ingrowth of squamous tissue (“secondary acquired keratoma”) (Figure 3, see page 847).
Acquired keratoma is also a rare but
potentially serious consequence of tympanostomy tube placement, following
which the eardrum may be weak or perforated at the site of the extruded tube.28
Acquired keratomas are identified as a
PEDIATRIC ANNALS 33:12 | DECEMBER 2004
collection of pearly white squamous
debris associated with an irregular or
perforated tympanic membrane, often in
a superior location. The process is frequently obscured by a layer of purulent
drainage or granulation tissue, as the keratomatous debris serves as an excellent
culture medium for bacteria.
Treatment of the associated bacterial
infection with ototopical medication
often simplifies the diagnosis. Many
patients have hearing loss on audiometric screening, especially in the presence
of a large perforation or ossicular erosion. Some patients have remarkably
good hearing, however, due to conduction of sound through the cholesteatoma
to the oval window.
Once the diagnosis of keratoma is
suspected, referral to the otolaryngologist is imperative. Delayed referral may
lead to complications including facial
nerve paralysis, semicircular canal erosion with labyrinthine fistula, ossicular
erosion, periosteal abscess, lateral sinus
thrombosis, and intracranial abscess.
Computed tomography is necessary to
define the extent and to plan the surgical
removal of the disease. Tympanoplasty
with or without mastoidectomy is usually necessary, including repair of the
damaged eardrum.
Foreign Body
Although even foreign bodies of long
duration are often asymptomatic, they
occasionally present with unilateral otalgia and otorrhea, much like otitis externa. Parents are usually unaware that the
drainage is associated with a foreign
body, and the object is often apparent
only after thorough debridement.
Once a foreign body is identified, the
first attempt at removal is usually the
best, and may be the last before a trip to
the operating room or conscious sedation is necessary. Irrigation is to be
avoided in most cases, since this may
push the foreign body deeper and the
PEDIATRIC ANNALS 33:12 | DECEMBER 2004
Figure 3. The posterosuperior quadrant and pars flaccida are the most common locations for acquired
cholesteatoma.
child may become increasingly anxious.
Some objects, such as beans, may
expand in the presence of moisture making removal even more difficult. Referral to an otolaryngologist should be considered since removal may be difficult
and complete inspection of the canal
and tympanic membrane are necessary.
If removal is undertaken, the shape, texture, and orientation of the object must
be studied. A wide variety of instruments should be available, including:
alligator forceps for objects with edges;
Hartmann forceps and wax loops for
round objects; and Rosen and right
angle picks for soft foreign bodies and
those with holes. A Baron suction tip is
very useful to debride blood and to aid
with the extraction. After removal, it is
usually wise to prescribe a topical
antibiotic-steroid mixture for any
drainage and to reduce the inflammation
created by the foreign body and the
extraction procedure.
Cerebrospinal Fluid Otorrhea and
Perilymphatic Fistula
Clear discharge from the ear is rare
but may suggest the presence of a leak
of cerebrospinal fluid (CSF) or perilymph. These disorders result from a
violation of the normal bony contours of
the ear due to trauma, congenital malformation, or erosive processes. In most
cases, patients complain of aural fullness, and examination reveals fluid in
the ear canal that reaccumulates when
evacuated. Occasionally, such patients
present with dizziness, hearing loss, or
recurrent bouts of meningitis.
Diagnosis of a CSF or perilymph
leak is made by sampling the fluid and
by imaging studies. A fluid sample with
a glucose concentration of approximate-
847
ly 60% of the serum value and a protein
concentration of less than 200 mg/dL is
most likely CSF or perilymph. ␤2 transferrin has also been described as a marker for perilymph;29,30 however, some
investigators have questioned the reliability of this test.31,32 The location of a
CSF leak may be established using computerized tomography with intrathecal
contrast or nuclear scans with intrathe-
tors, and drainage from the middle ear
due to otitis media. Trauma to the canal
skin can also lead to Pseudomonas
infection, most likely due to interruption
of the protective layers of cerumen and
skin and to local pH changes. Based on
biochemical and growth characteristics,
strains isolated from patients with otitis
externa more closely resemble those of
Pseudomonas in its natural water habitat
Debridement of the ear canal is
unquestionably the most critical step in the
diagnosis and management of otorrhea.
cal radionuclides. CSF leaks may heal
spontaneously, or may require exploration through a variety of approaches,
depending on the cause and location of
the leak.
MICROBIOLOGY OF OTORRHEA
While most pediatricians are familiar
with the conditions favoring infection
by otitis media organisms, the presence
of Pseudomonas in the ear is often less
well understood. Pseudomonas is an
aerobic, motile gram-negative rod commonly found in moist environments
such as water, sewage, and soil. In the
ear, P. aeruginosa is rarely culturable
unless there is infection present.33,34
Patients who develop otorrhea due to
Pseudomonas tend to retain moisture in
the ear canal due to stenosis or excessive
cerumen, and the prevalence of
Pseudomonas in the external canal is
known to increase with increasing water
exposure.33 Other sources of moisture in
the ear canal that may be associated with
Pseudomonas infection include humid
air, perspiration from wearing tightly fitted hearing aid molds or hearing protec-
848
than those associated with other infections in humans.35
In cases of tympanostomy tube otorrhea, drainage is most often precipitated
by upper respiratory colonization or
infection by one of the usual otitis media
organisms (S. pneumoniae, H. influenzae, or M. catarrhalis), particularly during the colder months of the year. However, within hours to days, increased
moisture in the ear canal allows
Pseudomonas to multiply and become
the predominant organism.10,36 During
summer months, otorrhea in the presence of tubes often starts as a
Pseudomonas or Staphylococcus infection resulting from contamination from
external sources.11,37 In about 10% of
cases, at least one organism from each
of these two groups may be isolated.37
Other organisms, including Staphylococcus epidermidis, Neisseria sp., diphtheroids, enterococcus, Proteus mirabilis, and Enterobacter cloacae, have
been demonstrated in more 60% of
cases.36,38 Anaerobes may also play a
role in otorrhea, as suggested by one
study in which these organisms were
cultured from 49% of cases.36 Chronic
otorrhea may also result from opportunistic infections by Aspergillus and
Candida species.
In otitis externa, P. aeruginosa is the
most common infecting organism
(61%), although cultures from the ear
canal often demonstrate a polymicrobial infection (44%).39 Chronic or
recurrent external otitis may result from
fungal infections; from skin conditions
such as eczema, seborrhea, or psoriasis;
or from poor aural hygiene or trauma in
stenotic ear canals. In chronic suppurative otitis media (CSOM), the organisms are similar to those in otitis externa, with Pseudomonas being the most
common isolate (37% to 84%).40,41
However, most cultures (5% to 58%)
demonstrate polymicrobial infections,
including gram-negative bacilli, S.
aureus, and anaerobes.22,23,25,40,41 Uncommon causes of CSOM include
tuberculosis and syphilis, as well as
noninfectious causes such as histiocytosis and rhabdomyosarcoma.
TREATMENT OF THE DRAINING EAR
The Initial Visit
Debridement of the ear canal is
unquestionably the most critical step in
the diagnosis and management of otorrhea. In the presence of significant canal
swelling or otorrhea, determination of
the cause of the drainage is not possible,
and the treating physician may be uncertain whether to treat the patient for otitis
media or otitis externa. Furthermore,
removal of the drainage is necessary so
that applied ototopical medication can
reach the target pathology.
Before debridement, the ear canal
must be visualized adequately, to minimize canal wall trauma and optimize
examination of the tympanic membrane.
This is best accomplished using a headlight, which keeps the examiner’s hands
free for retraction of the auricle and
PEDIATRIC ANNALS 33:12 | DECEMBER 2004
instrumentation of the ear. Headlights
serve a similar role in examination of
the nose and throat and are an invaluable
addition to any pediatric practice.
Debridement of the canal is performed using swabs or a small suction
device. Suction is generally quicker,
more effective, and less traumatic to the
canal wall, but the noise may be frightening to some patients, and the necessary equipment is not available in most
pediatric practices. Cotton-tipped applicators, self-made cotton swabs, or small
calcium alginate swabs, on the other
hand, clear the majority of the drainage
with less trauma to the canal walls.
However, debridement using this technique is often insufficient to afford an
adequate view of the tympanic membrane. Irrigation of the canal with room
temperature saline for this purpose
should be performed with extreme caution due to the potential for vertigo from
caloric stimulation, particularly in
patients with tubes or perforations.
Once the source of the otorrhea has
been established, topical antibiotic therapy is usually indicated. Selection of an
appropriate ototopical and duration of
therapy is addressed later in this article.
If adequate visualization of the ear canal
and tympanic membrane are not possible due to poor patient cooperation, a
trial of ototopical medication is still reasonable prior to considering referral to
an otolaryngologist. In the presence of
tympanic membrane perforation or tympanostomy tubes, oral antibiotics are
rarely indicated; otorrhea concentrations
of antibiotics administered through the
eardrum are 100 to 1,000 times greater
than those achieved with systemic therapy and likely exceed the and likely
exceed the MIC90 (the minimum concentration at which 90% of tested strains
are inhibited) for a longer time.42 The
topical route also reduces the potential
for alterations in bacterial flora at other
sites and the likelihood of inducing bacterial resistance. Parents should be
instructed to debride the ear with twisted tissue paper or cotton prior to admin-
Figure 4. Otowicks may be used to expand the
swollen ear canal and to keep the canal skin in
contact with topically applied medications
istering drops and to let each drop settle
through the canal before the next is
given. Tragal pressure applied afterwards ensures that the medication reaches the middle ear space.43
TABLE.
Ototopic Antibiotic Preparations
Brand Name
Antimicrobral
Solvent/Antiseptic
Steroid
Chloromycetin otic
Chloramphenicol
Propylene glycol
None
Ciloxan ophthalmic solution
Ciprofloxacin
Benzalkonium chloride
None
Cipro HC otic
Ciprofloxacin
Polyvinyl alcohol
Hydrocortisone
Ciprodex otic
Ciprofloxacin
Polyvinyl alcohol
Dexamethasone
Colymycin S otic
Neomycin, polymyxin B
Aqueous
Hydrocortisone
Cortisporin otic solution
Neomycin, polymyxin B
Propylene glycol, HCl
Hydrocortisone
Cortisporin otic suspension
Neomycin, polymyxin B
Propylene glycol, alcohol
Hydrocortisone
Floxin otic
Ofloxacin
Benzalkonium chloride
None
Lidex solution
None
Propylene glycol, alcohol
Fluocinonide
Lotrimin solution
Clotrimazole
Polyethylene glycol
None
Otocort suspension
Neomycin, polymyxin B
Propylene glycol, alcohol
Hydrocortisone
Pediotic suspension
Neomycin, polymyxin B
Propylene glycol, alcohol
Hydrocortisone
Tobradex ophthalmic solution
Tobramycin
Benzalkonium chloride
Dexamethasone
Vosol HC solution
None
Acetic acid, propylene glycol
Hydrocortisone
PEDIATRIC ANNALS 33:12 | DECEMBER 2004
849
When swelling obscures the tympanic membrane or pain is severe, placement of an expandable methylcellulose
otowick or sponge maximizes exposure
of the canal walls to ototopical medication and reduces drainage through the
tube or perforation if one is present (Figure 4, see page 849). After 2 to 4 days,
the wick is removed and the drops may
then be delivered directly to the external
The earliest ototopical antibiotic
preparations included sulfathiazole
ascorbate and sodium penicillin-sulfathiazole.44 Chloramphenicol, streptomycin, erythromycin, and aminoglycosides later became available in a variety
of powders and solutions. In the 1960s,
an ototopical containing neomycin (an
aminoglycoside), polymyxin B (a
polypeptide antibiotic), and hydrocorti-
Treatments for otorrhea during the past
four centuries have included red lead, tree
resin, frankincense, goose grease, cream,
vermilion, cumin, olive oil, and hatet oil.
canal, as edema most likely will have
subsided. The swelling should be reduced sufficiently within several days to
complete the examination of the ear.
Narcotic analgesics may be necessary
for pain management during the first
few days of treatment.
Ototopic therapy
Treatments for otorrhea during the
past four centuries have included red
lead, tree resin, frankincense, goose
grease, cream from cow’s milk, vermilion, cumin, ass ear, olive oil, and hatet
oil.44 By the first half of the 20th century,
medical science had evolved such that
astringents and antiseptics were the preferred therapeutic modalities; for many
physicians, these agents remain the treatment of choice.44 However, the advent of
antibiotics some 60 years ago brought a
shift in therapy toward the use of ototopical antibiotic preparations. Though there
are many ototopical medications available for use, each has its own identity and
indications (Table, see page 849).
850
sone emerged as the preferred therapy
for otorrhea. However, cases of
neomycin allergy began to appear, presenting as erythema and swelling of the
auricle with peeling of the skin. In addition, data from animal studies beginning
in the late 1960s suggested all of these
medications, as well as their carriers and
solvents, have inflammatory and ototoxic potential.45-47 Toxic effects included
inner and outer hair cell destruction,
squamous metaplasia and growth into
the middle ear, cholesteatoma, hearing
loss, damage to the stria vascularis,
adhesion formation, and mucosal
inflammation.
Nevertheless, few reports in human
subjects subsequently confirmed these
effects, perhaps owing to greater thickness of the human round window membrane, especially in the setting of
inflammation.48-52 As of the 1990s, combination preparations were still the
most commonly used, although some
physicians continued off-label use of
ophthalmic aminoglycoside medica-
tions.53,54 However, a 2004 consensus
panel of the American Academy of Otolaryngology – Head and Neck Surgery
concluded that “when possible, topical
antibiotic preparations free of potential
ototoxicity should be used in preference
to ototopical preparations that have the
potential for otologic injury if the middle ear or mastoid are open,” and that “if
used, potentially ototoxic antibiotic
preparation should be used only in
infected ears.”55
During the past decade, ototopical
preparations containing fluoroquinolone
antibiotics have appeared on the market.
Ofloxacin was the first such ototopical
available. Ciprofloxacin, which had
been used off-label in ophthalmic form
for several years, later became available
for otic use in a combination preparation
with hydrocortisone and is now available in combination with dexamethasone. Only ciprofloxacin is available
with steroid medication, which often is
required to control granulation tissue
involving the tympanic membrane and
middle ear. Steroids also seem to
improve the efficacy of ciprofloxacin in
the treatment of acute otitis media and
otorrhea through tympanostomy tubes.56
In studies of possible inner ear effects of
these medications, neither ciprofloxacin
nor ofloxacin has demonstrated ototoxic
potential.57-63
Both preparations are dosed twice
per day, compared with three times per
day for the neomycin–polymyxin
B–hydrocortisone combination. However, both are also more costly and may be
difficult to find on the formularies of
some third-party payors.
Sensitivity studies of aural pathogens
treated topically must be interpreted
with caution, as traditional susceptibility breakpoints are established only for
systemically administered medications.
In studies of acute tympanostomy tube
otorrhea, ototopic agents demonstrated
equal or greater clinical efficacy, superi-
PEDIATRIC ANNALS 33:12 | DECEMBER 2004
or eradication of pathogens, and fewer
adverse effects when compared with
oral antimicrobials.58,64 However,
although both ofloxacin and ciprofloxacin–dexamethasone have FDA
approval for use in infections by “otitis
media” organisms, ciprofloxacin has
demonstrated efficacy superior or equal
to that of ofloxacin among isolates from
patients with chronic otitis and sinusitis,65 as well as among isolates of S.
pneumoniae, H. influenzae, and M.
catarrhalis from all sources.66-70 An in
vivo study of ototopical therapy in
patients with acute otitis media through
tympanostomy tubes also found
ciprofloxacin–dexamethasone more
effective than ofloxacin.71
Aural isolates of P. aeruginosa have
demonstrated little resistance to antibiotics in common ototopical preparations.
In vitro susceptibility rates for polymyxin B, gentamicin, colistin, norfloxacin,
ciprofloxacin, and ofloxacin in most
studies are greater than 95%,58,65,72-74
although one study found 13% resistance to ofloxacin.65 Both ofloxacin
and ciprofloxacin have demonstrated
high efficacy in vitro and in vivo in the
management of otorrhea due to P.
aeruginosa and S. aureus.57-59,64,72-76
However, recent literature suggests the
emergence of strains of P. aeruginosa
that are resistant to the fluoroquinolones, as well as an increasing
prevalence of methicillin-resistant S.
aureus, which also may be fluoroquinolone-resistant.77-80 Neo-mycin and
chloramphenicol demonstrate poor efficacy, with susceptibility rates of just
17.8% and 13.4%, respectively.72,73
Cases in which fungal elements are
seen or yeast or fungus are identified by
culture may be treated with topical antifungal agents such as clotrimazole
dematologic solution.10 Such therapy
may be administered in alternating
doses with a topical antibiotic if a mixed
infection is present.
PEDIATRIC ANNALS 33:12 | DECEMBER 2004
Granulation tissue is a common
cause of drainage from the ear and may
be found in about 15% of ears with
tympanostomy tube otorrhea.81 Ototopical antibiotics combined with
steroids are more effective at clearing
granulation tissue than are ototopical
antibiotics alone.81 A 7-day to 14-day
course of medication is recommended;
however, the ear should be reassessed
for residual granulation after therapy. If
tissue persists, additional medication
may be useful. Alternatively, the otolaryngologist may be able to salvage
the tube by removing the granulation
polyp in the office setting. When all
other measures have failed, the tube
should be removed or replaced.
Steroid-containing ototopicals are also
useful in the treatment of dermatologic
conditions of the ear canal such as
eczema; in such cases, solutions containing steroid only (ie, fluocinonide)
also should be considered.
Systemic Antibiotic Therapy
Systemic therapy is rarely necessary
to treat otorrhea; most cases can be adequately treated with debridement and
topical therapy alone. In patients with
severe cellulitis possibly due to grampositive organisms, and in those cases
associated with upper respiratory infection of long duration in which bacterial
etiology is likely, additional systemic
therapy may be considered and should
be directed by cultures of the ear canal.
Patients with refractory chronic suppurative otitis of more than 6 weeks’ duration are also candidates for outpatient or
inpatient parenteral therapy combined
with daily aural toilet.
Pediatricians are quite familiar with
the oral and intravenous antimicrobials
indicated when otitis media organisms
are identified. (See the article by Dr.
Rosenfeld on page 833). In studies
investigating sensitivities of P. aeruginosa to common intravenous agents,
ceftazidime, piperacillin, and tobramycin had the best susceptibility profiles for Pseudomonas; ticarcillin and
gentamicin also were effective.73,82
Aural isolates of S. aureus are exquisitely sensitive to ciprofloxacin, ofloxacin, and trimethoprim–sulfamethoxazole, less so to gentamicin and chloramphenicol, and resistant to polymyxin
B.65,73,74 When culture results are not
available, agents such as azlocillin,
mezlocillin and ticarcillin/ sulbactam
provide good coverage for both middle
ear and external ear pathogens. Systemic
use of cipro-floxacin may be considered
for older children but at this time
remains unapproved for young children
due to the theoretical risk of bone or cartilage toxicity.83
Intravenous azlocillin, mezlocillin,
and ticarcillin–clavulanic acid have
demonstrated efficacy in the treatment
of chronic suppurative otitis.22,23,25,27
Some investigators have recommended
continued oral antibiotics as prophylaxis following intravenous therapy; however, Fliss et al.23 found no statistically
significant difference in recurrence rate
with the use of amoxicillin prophylaxis.
Follow-up for Draining Ears
Once the otorrhea has cleared, examination of the ear canal and tympanic
membrane should be completed.
Retained tympanostomy tubes and
eardrum perforations occasionally
develop granulation tissue peripherally
or in the lumen that responds to topically administered steroid-containing preparations if one was not chosen as initial
therapy. Tubes also may become occluded with inspissated debris and may
require disimpaction manually or with
hydrogen peroxide drops. When no tube
or perforation is appreciated and the history does not suggest otitis externa, the
pediatrician should examine the
eardrum carefully for retraction pockets
or squamous debris suggestive of
851
cholesteatoma. Timely otolaryngologic
referral should be made when otorrhea
is refractory to therapy or an etiology
cannot be established.
SUMMARY
There are a variety of causes of otorrhea in children. The most important
factor in reaching the proper diagnosis
and providing relief of the problem is
aural toilet. Once adequate debridement
has been performed, the diagnosis is
usually clearer, and treatment with ototopicals is significantly more effective.
Most cases of otorrhea are due to
infection or granulation tissue and can
be managed initially with appropriately
selected ototopical medication, thereby
avoiding the risks and side effects of
systemic therapy and the need for referral to a specialist. However, otorrhea in
children that is refractory to medical
therapy may be due to retained tympanostomy tubes or insidious pathology
such as cholesteatoma or malignancy. In
such cases, prompt referral to the otolaryngologist can facilitate accurate
diagnosis and successful management.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
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