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How to diagnose and manage ear discharge
Mrs Smith had brought in her three-year-old son Matthew a few days ago to see another partner. Matthew had been crying and pulling at his ear. After a brief examination the partner had advised Mrs Smith to give her son paracetamol.
This morning the boy woke up with a bloody discharge over his pillow but the pain has gone. Mrs Smith is clearly upset and feels earlier antibiotics would have been appropriate and is not satisfied with the care she received.
Dr Tanvir Jamil discusses.
What's the first step?
Follow the golden rule always listen to the angry patient. Give them even more time then usual. This often has the effect of diffusing the situation if they feel able to 'air' their grievance. Don't just assume this is a simple case of otitis media (OM). Ask about:
·Past history: 40 per cent of children suffer one or more episodes before the age of 10. 'Recurrent otitis media' is three or more episodes in six months, or four or more in a year.
·Family history: children inherit their parents' genes for narrow eustachian tubes and atopy.
·Pain and discharge: recent perforation of the drum in OM is usually accompanied by a blood-stained profuse discharge. The child feels better with little or no pain as the tension on the drum is relieved, but parents worry about the blood. Discharge in otitis externa (OE) contains flakey cell debris and patients often present with itching in the ear rather than pain.
Boils (furunculosis) are caused by infection of the hair follicles in the outer third of the external auditory meatus (EAM). Pain is often worse on moving the jaw (eating or talking) and subsides if the boil bursts.
·Deafness: perforation of the drum causes deafness in OM and a child may have been seen already with ear infections and/or speech delay. Deafness can occur in otitis externa if the EAM becomes full of debris or the infection spreads into the surrounding tissues causing swelling and narrowing of the EAM.
·Skin conditions: otitis externa can occur in children with eczema. Swimmers are also prone as they get water-macerated ears.
·Trauma: blood can occur in the EAM from overzealous cleaning.
Is there much to be gained by examination if there is discharge present?
It's definitely worth doing a careful examination of the whole ear and mastoid, not just the EAM. Gentle suction of the discharge (with a large bore syringe without needle!) might also be revealing. Again with an upset patient or parent a careful step-by-step examination will show you are taking their problem seriously.
·Auriscopic examination: otalgia due to a boils, AOM and OE tends to worsen on moving the tragus and pulling back the pinna. Discharge can make visualisation of the tympanic membrane impossible but contralateral tympanic membrane often shows signs of OM as well. Look for change in colour to pink/ red, bulging and loss of outline of the drum and landmarks plus perforation.
·A boil may start off as a diffuse red swelling of the outer EAM. This can localise to a very tender swelling which can occasionally completely occlude the EAM.
·In OE the EAM can appear red, swollen or scaly with debris in the lumen. There is tenderness on moving the jaw and occasional regional lymphadenopathy. Untreated OE can present with infection having spread to surrounding tissues causing severe pain, swelling and cellulitis of the surrounding area.
Are investigations appropriate at this stage?
Probably not. Swabs are usually only worth doing if first-line treatment fails.
Urinalysis is also something to consider to exclude diabetes mellitus in recurrent infections particularly boils.
Sounds like five days of Amoxycillin should help Matthew
·Yes, if it is OM. For patients with a penicillin allergy, clarithromycin or azithromycin are both effective. Erythromycin is often given but it lacks activity against H. influenza. Most GPs still prescribe a course for five days although the Standing Medical Advisory Committee (1998) recommends three days. Other helpful measures include adequate analgesia and eustachian tube exercises, eg asking a child to blow up a balloon regularly.
·Don't forget to review the patient after three-four weeks to visualise the tympanic membrane to ensure no perforations persist.
·In mild cases of OE topical antibiotics are adequate. Excessive discharge and cell debris must be removed by syringing before drops are applied. If the ear drum is perforated the CSM advises the use of aminoglycosides (eg gentamicin) or polymyxins with caution. Patients with spreading cellulitis need oral, sometimes IV, antibiotics. Advise patients not to block off drainage with cotton wool, not to scratch with towels or fingers and avoid cleaning with cotton buds.
Are there are red flags I should be looking for?
·Mastoiditis or cholesteatoma should be suspected in those with discharging ears of greater than 10 days' duration.
·Cholesteatoma gives a foul-smelling discharge, fails to respond to antibiotics, and often causes attic or posterior perforations. An untreated cholesteatoma can cause conductive or sensorineural deafness. Refer to ENT if suspected.
·Heat, tenderness and swelling over the mastoid process suggest mastoiditis. Classically downward displacement of the pinna so that the 'ear sticks out' implies subperiosteal abscess formation. Mastoiditis was a sequelae in 1-5 per cent of OM sufferers in pre-antibiotic days. Any suspicion warrants immediate referral.
·Herpetic infection may cause, discharge severe pain accompanied by facial paralysis (Ramsay Hunt syndrome).
·Otitis media can cause fever, vomiting and loss of appetite, especially in young children. Irritability may be the only sign in babies.
Is there anything else I need to consider?
·It's definitely worth explaining to Mrs Smith your partner's management
plan. Starting off with something like: 'I'm sorry you're upset about your
son's illness. However, specialists do advise us to hang on a few days to see
if the problem clears up by itself. That way we don't use unnecessary antibiotics.'
·You could have a chat with your partner about the case and if there is anything he feels he could have handled differently, although this needs to be done with the utmost sensitivity.
Tanvir Jamil is a GP in Burnham, Buckinghamshire