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Treating otorrhea with oral antibiotics is not always successful, and the alternatives--referral for frequent suctioning and possible surgery--can be traumatic and costly. Newly approved fluoroquinolone otic drops offer another choice.
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By Richard H. Schwartz, MD, and Robert S. Bahadori, MD
Treating otorrhea with oral antibiotics is not always successful,and the alternatives--referral for frequent suctioning and possible surgery--canbe traumatic and costly. Newly approved fluoroquinolone otic drops offeranother choice.
Otorrhea is a fairly frequent complaint in the pediatric age group, oftenrecalcitrant to treatment and with a potential for serious complications.This overview will help you understand the varied causes of this condition,make an accurate diagnosis, and decide on a effective course of management.
Otorrhea can be acute or chronic, and its origin can be either the middleear or the auditory canal. Acute otorrhea (ICD-9 code 388.60) is definedas drainage from the ear lasting less than six weeks. Drainage that lastsfrom three to six weeks may be called subacute; drainage that lasts longerthan six weeks is designated as chronic. Acute otorrhea is fivetimes morecommon than chronic drainage.1
Data from Dr. Schwartz's suburban private pediatric practice during atwo-year period ending in June 1997 indicate some common causes of otorrhea.Of 23 children presenting with acute otorrhea, 16 (69%) had tympanostomytubes and seven had acute otitis media (AOM) and otorrhea through an acutelyperforated eardrum. Twelve of the children (52%) made multiple visits forthis problem.
Chronic otorrhea is usually due to chronic suppurative otitis media,granulation tissue on the middle ear mucosa, or immune deficiency. Unlesstreated adequately, chronic otorrhea may lead to hearing loss.
The usual treatment for chronic otorrhea is frequent suctioning of thedrainage, instillation of antibiotic drops into the dry ear canal, and parenteralantibiotic therapy. Research data suggest that topical therapy alone, usingbroad spectrum fluoroquinolone antibiotic otic drops, may be equally successfulin the treatment of acute otorrhea, otorrhea associated with tympanostomytubes, and chronic otorrhea.24 Such a regimen would be moreconvenient for patients and--because topical drops reach only the ear canaland the normally sterile middle ear--less likely to promote antimicrobialresistance than systemic antibiotics. And while a unit of ofloxacin costsabout four times more than a bottle of amoxicillin at a local pharmacy inthe Virginia suburb where Dr. Schwartz practices ($36 for a 10 mL bottleof ofloxacin, compared to $7.95 for 150 mL of amoxicillin suspension), itcosts about half the price of some of the broad spectrum antibiotics pediatriciansresort to when organisms prove resistant to amoxicillin, such as amoxicillin/clavulanate.
Before deciding on a treatment for acute otorrhea, the physician mustdetermine the character and duration of the discharge and locate its exactsource, usually the middle ear. The age of the child and the presence orabsence of tympanostomy tubes are other important facts to seek when takingthe history and performing the physical exam. During the swimming season,severe otitis externa may be associated with weeping from the auditory meatus,crusting of the ear lobe, and occasionally tenderness and swelling of thepostauricular lymph nodes.
The character of the discharge can be a clue to its origin, althoughit is not always predictive of etiology. Types of discharge include:
In infants, toddlers, and preschool children, acute otorrhea usuallyhas one of three causes:
Tympanostomy tubes. Otorrhea is the most common complication followinginsertion of tympanostomy tubes for the treatment of otitis media.1,5,6The reported incidence of otorrhea in children with tubes ranges from 15%to 50%, depending on the type of tube used and the population studied. Mostinvestigators cite incidence figures of about 20%.1 Otorrheaoccurs within two weeks of tube insertion in 3% to 5% of young children,and is more likely to be related tothe presence of purulent fluid at thetime of the surgical procedure than to contamination through the tube oranother acute infection. Herzon noted a 7.9% incidence of otorrhea in thefirst 10 days after surgery.7 Instillation of antibiotic dropsat the conclusion of tympanostomy tube surgery can reduce the frequencyof postoperative otorrhea.810
Otorrhea may also occur weeks or months after tube insertion, as a resultof water contamination after showering or swimming or as part of a new episodeof acute otitis media. About 4% of children with tubes who swim withoutear plugs can be expected to develop acute otorrhea.1113Diving and swimming two or more feet below the surface may increase thefrequency of otorrhea in children with tubes and should be strongly discouraged.Persistent purulent otorrhea resistant to conventional medical therapy isusually secondary to granulation tissue around or within the tympanostomytube.5
AOM with ruptured membranes. In our practice, otorrhea through spontaneousrupture of an intact tympanic membrane occurs in three to five childreneach year. Cultures of the discharge show typical middle ear pathogens:pneumococcus, Haemophilus influenzae, and Streptococcus pyogenes. With antibiotictherapy, the perforation site usually heals within 48 hours, almost invariablywithout residual hearing impairment. Infection caused by S pyogenes hasthe greatest potential for causing middle ear complications if not adequatelytreated with antibiotics.
Otitis externa. Advanced cases of otitis externa with severe weepingedema of the ear canal may produce otorrhea. The aural discharge is heavilycolonized by bacteria, usually Pseudomonas species.
Less common causes. A draining pustule or furuncle or a ruptured blisterfrom poison ivy or impetigo may cause a few drops of sticky otorrhea. Crystalclear otorrhea may be a cerebrospinal fluid leak caused by trauma and perforationof the tympanic membrane and the oval or round window. Cerebrospinal fluidmay be detected by a positive glucose oxidase paper test, but in cases ofclear otorrhea the clinician should always ask for a history of trauma--ablow to the ear, deep diving, or a change in airplane altitude--as well.Analysis of the otorrhea fluid for b2 transferrin, a proteinmarker unique to cerebrospinal fluid, may offer a more precise diagnosis.14Barotrauma as a result of deepocean diving may lead to a perforated eardrumand bloody otorrhea. Treatment of CSF or bloody otorrhea requires consultationwith an otolaryngologist.
Treatment options. Pediatricians usually prescribe oral antibiotics foracute otorrhea associated with tubes, while otolaryngologists often treatthe condition with suctioning and otic drops or ophthalmic drops such assulfacetamide sodium prednisolone acetate (Blephamide). Whileneomycin, gentamicin,and tobramycin otic drops have been shown to be toxic to the cochlea andthe vestibule in rodents, fluoroquinoloneotic drops have not.8,1518For this reason, only ofloxacin otic solution (Floxin otic) has receivedFDA clearance for use in the middle-ear cavity of human subjects.
Otorrhea following rupture of the membranes in AOM may be appropriatelytreated with oral antibiotics.1113 Culture and sensitivityresults are sometimes helpful in detecting antibiotic-resistant bacteriaquickly, permitting accurate therapy. However, a recent study has shownthat topical therapy with 0.25 mL of 0.3% ofloxacin otic solution may effectivelyreplace oral antibiotic therapy, as long as the perforation is large enoughto permit the drops to enter the tympanum.2,19
Otorrhea associated with swimming is usually easily managed with antibioticdrops in the ear canal. When otorrhea occurs with granulation tissue aroundthe tube, the first step in management is to keep the ear dry with frequentsuctioning. Antibiotic drops administered once or twice daily for severalweeks may be curative. Recalcitrant cases should be referred to an otolaryngologist.
For otorrhea associated with otitis externa, the most important managementstep otolaryngologists recommend is gentle but thorough suction or lavageof the ear canal. Omission of this measure is one of the most frequent reasonsfor failure to improve. Because the canal is extremely tender, analgesicpremedication may be necessary before lavage or suctioning is performed.Insertion of an expandable otowick (Pope's otowick, Xomed Co., Memphis,TN) usually achieves partial resolution of the inflammation after 24 to48 hours and allows unhurried pneumo-otoscopic examination. Instillationof 2% acetic acid solution or Domeboro otic solution every few hours forone day is usually an effective initial treatment. Our recently completedstudy indicates that this step may be omitted if fluoroquinolone drops areused. If there is significant canal wall inflammation (redness and significantcanal wall edema), an antibiotic/ corticosteroid otic drop may be helpful.
A few practical points:
Although some physicians look upon chronic otorrhea as an annoying butbenign condition, serious complications can occur. These include aural cholesteatoma,permanent conductive hearing loss, chronic otomastoiditis, and, in rareinstances, invasion of mastoid bone (osteitis) or intracranial contents.20
Causes. The hallmark of chronic otorrhea is middle ear drainage througha perforated tympanic membrane that lasts for at least six weeks. The conditionis most often caused by partially treated or untreated chronic suppurativeotitis media (CSOM).21 Inflammatory granulation tissue in themiddle ear may accompany the CSOM. The cause of the infection may be cholesteatoma,but in most cases CSOM results from a partially treated or untreated acutesuppurative otitis media. Although the incidence of CSOM without cholesteatomahas not been studied, research in Alaskan natives and southwestern NativeAmericans indicates the incidence peaks in the pediatric population duringthe first three years of life and declines after 5 years of age.22,23Because the condition is not common in the US, few pediatricians have hadexperience managing it
Causes of chronic otorrhea are listed in Table 2. Unusual causes includetuberculosis of the middle ear,24 histiocytosis X, Wegener'sgranulomatosis,and chronic fungalinfections that may require combined surgical and medicalmanagement.
In most cases of chronic otorrhea, opportunistic pathogens such asPseudomonasaeruginosa, staphylococci, Proteus species, and anaerobes predominate. Ifthe discharge is foul-smelling, anaerobic bacteria are probably involved.
Management. As with acute otorrhea, pediatricians and otolaryngologiststend to differ in the way they manage chronic otorrhea. For example, a surveyof 67 Dallas pediatricians showed that 37% would culture the drainage fromthe ear canal, all would prescribe an oral antibiotic, and 80% would alsoprescribe a topical antibiotic.25 When asked what they woulddo if a child fails to respond to such a regimen, 60% said they would trya different antibiotic and 40% would refer to an otolaryngologist. Noneof the pediatricians mentioned aural suctioning, a cornerstone of managementby otolaryngologists.
When otolaryngologists manage chronic otorrhea, they suction the earcanal frequently (three times a week, usually); instill antipseudomonaland antistaphylococcal drops or antifungal drops, and occasionallyuse oralantibiotics as well. When repeated suctioning and ear drops do not resolveacute or chronic otorrhea, many otolaryngologists advocate hospitalizationfor administration of intravenous antibiotics and possible otomastoid surgery.
Such drastic measures may no longer be necessary for many of these children,however. Accumulating data indicate that--with the exception of childrenwith aural cholesteatoma--children with chronically draining ears can bemanaged as outpatients with topical fluoroquinolone drops. The savings fromsuch a shift--in physical and emotional trauma for the patient and in hospitalcosts--would be significant.
The pediatric approach to both acute and chronic otorrhea has alwaysrelied on oral antibiotics as first line treatment. Patients with chronicotorrhea or recalcitrant acute otorrhea were referred to their colleaguesin otolaryngology.
Otolaryngologists have a different approach, involving frequent visitsfor repeated suctioning, the use of topical medications, and--if that wasn'tsufficient--surgery. Neither approach is ideal.
Now a new way of managing these conditions may be available, one thatcan clear up otorrhea in many cases with topical treatment using flouroquinoloneotic drops. This new management option is simpler, less likely to contributeto antibiotic resistance, and less traumatic for the patient. It's worthinvestigating.
DR. SCHWARTZ is Clinical Professor of Pediatrics, University of VirginiaSchool of Medicine, Charlottesville. He practices pediatrics at Vienna PediatricAssociates
in Vienna, VA.
DR. BAHADORI is Clinical Assistant Professor of Otolaryngology at GeorgetownUniversity School of Medicine in Washington, DC, and Clinical AssociateProfessor of Pediatrics at the University of Virginia School of Medicine,Charlottesville. The writing of this article was funded by an unrestrictededucational grant to the authors from Daiichi Corp., the manufacturer ofofloxacin otic drops.
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