From The Child's Doctor, Fall 2012
- Nancy M. Young, MD
- Head, Section of Otology/Neurotology and Medical Director, Audiology & Cochlear Implant Programs, Children's Memorial Hospital; The Lillian S. Wells Chair in Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago; Professor of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine; Professor, Department of Communication Sciences & Disorders, Northwestern University School of Communication
- Disclosure: Dr. Young has no industry relationships to disclose and does not refer
to products that are still investigational or not labeled for the use
- Stephen R. Hoff, MD
- Attending Physician, Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago; Assistant Professor of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine
- Disclosure: Dr. Hoff has no industry relationships to disclose and does not refer
to products that are still investigational or not labeled for the use
Other Disclosure Information
At the conclusion of this activity, participants will be able to:
- Discuss the differential diagnosis, evaluation and management of conditionspresenting with chronic draining ear
- Identify serious causes of chronic draining ear that require further investigation and possible surgical management
The draining ear is most often a sign of a common problem that is readily treatable in the office. Drainage that is occasional and does not reoccur soon after treatment is usually not of concern. However, persistent or frequent intermittent drainage may be a sign of underlying disease that requires further investigation and possibly surgical management.
Drainage from the ear may arise from inflammation of the ear canal skin and/or the surface of the tympanic membrane. Drainage also may arise from inflammatory disease within the middle ear, attic and mastoid. In these latter instances, perforation of the drum is present thereby permitting drainage to be present in the external canal. In the setting of trauma or rare congenital temporal bone malformations, drainage may be secondary to cerebrospinal fluid.
Otitis externa is a common cause of drainage from the ear. The most common bacterial pathogen is pseudomonas aureginosa. The hallmark of otitis externa is pain upon movement of the pinna. The amount of drainage is not profuse, as may occur from infections arising deeper within the ear. Oto-topical therapy alone is usually successful. However, in some instances, careful cleaning under the operating microscope may be necessary for ototopical therapy with an antibiotic drop to be effective. In chronic cases, cultures may be necessary to rule out resistant organisms. In some children, severe swelling of the ear canal may interfere with instillation of topical therapy. In this situation, placement of a wick in the ear canal usually renders topical therapy successful. However, occasionally hospital admission for intravenous antibiotic therapy and pain control is necessary if there is severe cellulitis and otalgia. In a young child, a foreign body within the ear canal may also cause otitis externa. The foreign body may be obscured by drainage or swelling of the ear canal. Malignant otitis externa, a life threatening disorder in which the skin infection spreads to the bone of the skull base, occurs in diabetics. This complication is rare in children as pediatric diabetics do not have disease of the cutaneous small blood vessels that predisposes adult diabetics to this complication.
Otitis media with & without PE tubes
Acute otitis media (AOM) with spontaneous perforation is a common cause of otorrhea. The onset of drainage typically coincides with pain relief. Treatment with an oral antibiotic with or without oto-topical therapy is common practice and a reasonable approach. Follow-up examination to determine that the drum has healed is beneficial. Tympanic membrane mobility with pneumatic otoscopy is a helpful office procedure to confirm that the drum has healed.
Acute otitis media in an ear with a patent PE tube or chronic perforation is typically associated with otorrhea. The drainage may range from scant to profuse and may be clear, discolored or blood tinged. Pain and fever are often absent. Oto-topical therapy alone is usually successful, therefore oral antibiotics are best reserved for children exhibiting systemic signs of infection. Follow-up office examination to ensure that the drainage has resolved is helpful, as diminished but persistent otorrhea may not be appreciated by the parent.
A minority of children who undergo PE tube placement to address recurrent AOM continue to experience frequent ear infections despite the presence of patent tubes. Aggressive office management that includes repeated suctioning of the ears and use of oto-topical therapy often will resolve this problem. However, some children have a predisposition to ear infections that is not significantly impacted by the improved middle ear ventilation provided by PE tubes. In these cases, continued infection may be a sign of an immune deficiency, even in the absence of recurrent infections affecting other areas of the body. An immune work up may therefore be valuable. Other treatable factors that may impact the frequency of otitis media include allergies and bacterial sinusitis. Treating these underlying problems may ameliorate the frequency of otitis media. Adenoidectomy may improve the health of the upper respiratory tract and have a positive impact on both otitis media and sinusitis.
Onset of otorrhea in a child who had not previously experienced frequent or chronic otorrhea after PE tube placement may be a sign of foreign body reaction to the tube. The drainage is often frankly bloody. The presence of red, fleshy, granulation tissue adjacent to or covering the tube is the hallmark of this problem. However, the drainage caused by this inflammatory tissue may obscure its visualization. Granulation tissue may respond rapidly to common oto-topical medications such as ciprofloxacin/dexamethasone otic and ofloxacin otic. These medications are also safe for use in the middle ear, an important consideration as the tube may still be patent or become functional after shrinkage of the granulation tissue. If granulation tissue does not resolve, or quickly reoccurs, removal of the PE tube is necessary.
Recurrent otorrhea may also occur in children who have an undiagnosed perforation of the tympanic membrane. Otorrhea that repeatedly begins after swimming and does not have the typical presentation of otitis externa is suspicious for the presence of a perforation. Children with unrecognized tympanic membrane perforations are often infection-free during the winter months while not swimming. During this time period the presence of the perforation provides middle ear ventilation, as a patent PE tube would do. Observation of water precautions by use of well-fitting ear plugs to prevent water contamination of the middle ear may be all that is necessary to prevent infections in these children. In contrast, studies of children with PE tubes who swim in chlorinated pools have demonstrated that most do not experience an increase in acute otitis media. This difference is likely due to the fact that the opening in a PE tube is smaller than most perforations. Therefore, many otolaryngologists no longer routinely recommend ear plugs for children with patent PE tubes when they swim in pools, but do continue to suggest water precautions for those with perforations.
Chronic otorrhea not responsive to office management
Chronic or intermittent drainage that repeatedly reoccurs soon after each course of treatment may be a sign of cholesteatoma or chronic infection of the ear that may require major ear surgery. Eustachian tube dysfunction, an important factor in the genesis of otitis media, is an important underlying factor in the development of acquired cholesteatoma. Some children with a history of otitis media develop retraction of the ear drum into the attic, a small space above the middle ear. Deep retraction of either the pars flaccida or posterior superior aspect of the pars tensa, are common causes of attic cholesteatoma, the most common type of acquired cholesteatoma. Normally as the skin lining the outer surface of the drum desquamates, these dead cells are moved out of the ear by a process of migration. If the invaginated drum, which is often referred to as a retraction pocket, enlarges and extends more deeply inside the ear, the desquamated skin within the pocket no longer can be cleaned by this natural process of migration. The retraction pocket then enlarges and often perforates, spreading skin cells throughout the ear (Figure 1).
This process is typically painless even though the chemicals and enzymes released by cells surrounding the cholesteatoma cause erosion of bone. The cholesteatoma ultimately becomes infected. At first, the resulting otorrhea may appear to respond to topical and oral antibiotic therapy. However, the drainage will become more frequent and ultimately chronic as medical treatment is only able to suppress infection. In a child with a long history of intermittent infection secondary to otitis media, it can be difficult to tell when the underlying problem of chronic intermittent ear infections has evolved into acquired cholesteatoma as these disorders are part of a continuum of chronic ear disease. Cholesteatoma requires complete surgical removal to control the infection and to prevent complications secondary to bone erosion.
Congenital cholesteatoma is less common than acquired cholesteatoma and is also an important cause of chronic otorrhea. Although congenital cholesteatoma does not arise secondary to underlying chronic ear disease and eustachian tube dysfunction, these conditions may be comorbid. The presence of middle ear effusion secondary to otitis media may obscure the otoscopic finding of a white mass beneath an intact drum. If not diagnosed early, congenital cholesteatoma may grow to fill the middle ear, attic and mastoid and perforate the drum. Otorrhea may be the presenting sign of a congenital cholesteatoma in a child with an unremarkable history of otitis media. For either acquired or congenital cholesteatoma, examination of the ear using a microscope in the office or operating room is critical to diagnosis. Imaging studies may also be valuable in confirming the diagnosis, determining extent of disease and underlying anatomy. Early diagnosis of cholesteatoma is advantageous to avoid the risk of facial nerve paralysis and intracranial complications such as epidural abscess.
In some cases of persistent drainage, inflammatory disease within the ear without cholesteatoma is the culprit. Office cultures of the drainage may be helpful to determine if an organism resistant to the oto-topical agents is present and culture guided therapy may be more effective. Although chronic otorrhea secondary to methicillin-resistant Staphylococcus aureus (MRSA) is not common in the Chicago area, it is important to consider in children not responding to treatment. However, cultures obtained from the ear canal in the office may not reflect the true pathogens inside the ear. Therefore, intraoperative cultures may be beneficial. In cases where repeated meticulous office cleanings and culture guided therapy does not resolve the infection, tympanomastoidectomy surgery may be recommended. This surgery entails removing inflammatory tissue from the middle ear, attic and mastoid and thoroughly irrigating these areas. In some children occult cholesteatoma may be discovered during surgery as the underlying cause of infection. Surgery often improves the health of the ear to the degree that chronic infection is eliminated, although intermittent new episodes of acute otitis media may still occur if the child has persistence of underlying eustachian tube dysfunction.
A rare cause of otorrhea that is non-responsive to antimicrobial therapy is Langerhans cell histocytosis (LCH). This disorder may rarely have an initial presentation of otorrhea through a perforation. Computer tomography of the temporal bones reveals a destructive process that is not consistent with either cholesteatoma or chronic infection. Once this diagnosis is suspected, an area of skin involvement elsewhere on the body can usually be identified from which a skin biopsy may be taken to confirm the diagnosis.
Most drainage from the ear in children is related to otitis media and otitis externa, disorders that typically can be successfully managed in the office. However, frequently reoccurring or chronic drainage may be a sign of concomitant underlying disease that needs to be investigated. A high index of suspicion for cholesteatoma needs to be maintained for children with drainage that cannot be controlled by office management.
For Further Reading
[1.] Schroeder A, Darrow DH. Management of the draining ear in children. Pediatr Ann 2004 Dec;33(12):843-853.
[2.] Rosenfeld RM, Brown L, Cannon CR, et al. American Academy of Otolaryngology – Head and Neck Surgery Foundation. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg 2006 Apr;134(4 Suppl):S4-23.
[3.] Schmelzle J, Birtwhistle RV, Tan AKW. Acute otitis media in children with tympanostomy tubes. Can Fam Physician 2008 August;54(8):1123-1127.
[4.] Granath A, Rynnel-Dagoo B, Backheden M, Lindberg K. Tube associated otorrhea in children with recurrent acute otitis media: results of a prospective randomized study on bacteriology and topical treatment with or without systemic antibiotics. Int J Pediatr Otorhinolaryngol 2008 Aug;72(8):1225-1233.
[5.] Alexander NS, Kulbersh BD, Heath CH, et al. MRSA and non-MRSA otorrhea in children: a comparative study of clinical course. Arch Otolaryngol Head Neck Surg 2011;137(12):1223-1227.
[6.] Morpeth JF, Bent JP, Watson T. A comparison of cortisporin and ciprofloxacin otic drops as prophylaxis against posttympanostomy otorrhea. Int J Pediatr Otorhinolaryngol 2001 Nov 1;61(2):99-104.
[7.] Hebert RL, King GE, Bent JP. Tympanostomy tubes and water exposure: a practical model. Arch Otolaryngol Head Neck Surg 1998 Oct;124(10):1118-1121.
[8.] Isaacson G. Diagnosis of pediatric cholesteatoma. Pediatrics 2007 Sept 1;120(3):603-608.
[9.] Tyagi I, Syal R, Goyal A. Cerebrospinal fluid otorhinorrhoea due to inner-ear malformations: clinical presentation and new perspectives in management. J Laryngol Otol 2005 Sep;119(9):714-718.