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Gold, incentives and meh

Mother is upset by son's ear care



Mrs Smith brought in three-year-old Matthew a few days ago to see another partner. Matthew had been crying and pulling at his ear. She was advised to give her son paracetamol and he would be fine. This morning Matthew woke up with a bloody discharge on his pillow but the pain has gone. Mrs Smith is upset and feels earlier antibiotics would have been appropriate and is not satisfied with the care she received from your partner. Dr Tanvir Jamil discusses.

What's the first step?

Follow the golden rule – listen to the angry patient. Give them even more time than usual. This often has the effect of diffusing the situation if they feel able to 'air' their grievance. Don't assume this is just otitis media (OM). Ask about:

lPast 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.

lFamily history Children inherit their parents' genes for narrow eustachian tubes and atopy.

lPain and discharge Recent perforation of the drum in OM is usually accompanied by a bloodstained 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 flaky 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.

lDeafness Perforation of the drum causes deafness in OM and a child may have been seen already with previous ear infections and/or speech delay. Deafness sometimes occurs in OE if the EAM becomes full of debris or if the infection spreads into surrounding tissues causing swelling and narrowing of the EAM.

lSkin conditions OE can occur in children with eczema. Swimmers are also prone as they get water-macerated ears.

lTrauma 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.

lAuriscopic examination Otalgia due to a boil, 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. Look for change in colour to pink/red, bulging and loss of outline of the drum and landmarks plus perforation.

lA boil may start off as a diffuse red swelling of the outer EAM. This can localise to a tender swelling that can occasionally completely occlude the EAM.

lIn 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 amoxicillin should help?

lYes, if it's 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, such as asking a child to blow up a balloon regularly.

lDon't forget to review after three-four weeks to visualise the tympanic membrane to ensure no perforations persist.

lIn 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 intravenous, antibiotics.

Are there any red flags I should be looking for?

lMastoiditis or cholesteatoma should be suspected in those with discharging ears of greater than 10 days' duration.

lCholesteatoma 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.

lHeat, 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.

lHerpetic infection may cause discharge and severe pain accompanied by facial paralysis (Ramsay Hunt syndrome).

lOM 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?

lIt'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.'

lYou 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, a GP in Burnham, Buckinghamshire, is on a year's

sabbatical in Canada

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