Otorrhea

 


OVERVIEW: Otorrhea is often the presenting sign of many otologic disorders. Often the draining ear caused by various etiologies will present and look the same. The clinical history and physical exam is essential to creating a differential diagnosis and to subsequently developing a treatment plan.

ISSUE: How do we choose the appropriate therapy for the draining ear?

The differential diagnosis of otorrhea is long and ranges from the very common to the very obscure. One key element to narrowing the differential is the presence of or history of a tympanostomy tube.

Acute Otitis Media in the presence of a tympanostomy tube (AOMT) is likely the most common scenario of a child presenting with ear drainage in both primary care and specialist practices. The majority of these children can be treated with ototopical medications. Two nonototoxic topical medications options are FDA approved for the treatment of AOMT. They are ciprofloxacin/dexamethasone (0.3/0.1%) and ofloxacin (0.3%). The presence of significant inflammation, and particularly the presence of granulation tissue often contribute to the decision to choose the combination medication including the steroid component. Findings of blood-tinged otorrhea or visible granulation polyp are often seen in these children. In addition to the proper medication choice, the delivery of the medication is very important. Copious otorrhea can limit delivery and necessitate aural toilet measures. Dry wicking to allow ototopical drop placement is a good initial step that can be demonstrated to at-home caregivers. Pumping the tragus after drop placement improves delivery of the medication to the medial ear canal and middle ear. More extensive measures, such as irrigation and suctioning, are reserved for refractory cases. Culture of otorrhea can be an important adjunct, particularly in the face of recurrent or refractory otorrhea. Bacterial resistance to ototopical medications is rare due to the very high concentrations achieved at the site of infection (very different from blood stream concentration that MIC resistance information is based on). However, the presence of fungi on culture, particularly yeast, can require alternative therapy. Occasionally the addition of an oral antibiotic is helpful, primarily in the presence of comorbid infections such as sinusitis.

As summer approaches, the incidence of Otits Externa increases. With or without a history of recent swimming, otitis externa is a common etiology of otorrhea. Typically these patients present with painful, edematous ear canals that often are draining or filled with squamous debris. These patients are identified by lack of presence of a tympanostomy tube and typically more edema and pain of the ear canal, but less inflammation of the tympanic membrane. Ototopical medications are again the mainstay, but if the status of an intact tympanic membrane is uncertain, medications approved for use in the middle ear (see above) should be chosen unless contraindicated. Occasionally, patients with tympanostomy tubes present will present with more otitis externa features than AOMT. Usually these are older children, and typically respond to the standard treatments. In addition to medication, aural toilet is often essential to resolution of these infections. Because of ear canal edema, suctioning and/or irrigation with or without a wick is often needed.

Cases of otorrhea that are recurrent or refractory or that do not fit well with the typical clinical scenarios discussed above should raise the question of one of the more rare etiologies. Cholesteatoma, malignancy, CSF leak, etc., often have the initial presenting symptom of otorrhea and always need to be thought of when the clinical circumstances are unclear.

BOTTOM LINE: Most cases of otorrhea are due to common etiologies and can be treated in the primary care setting with ototopical medications. Occasionally oral medications are added based on the clinical situation. ENT specialist care may be required for refractory or recurrent cases, particularly when specialized aural toilet measures are necessary. Cases that present with unusual findings or do not respond to standard therapy may require ENT specialist evaluation to rule out rare causes such as cholesteatoma or tumor.

SUGGESTED READING:
Controversies in the Management of Otitis
ENT-Ear, Nose, and Throat Journal Supplement 1 Nov 2007 Vol 86 No 11

Managing Acute Otitis Media in Children with Tympanostomy Tubes
ENT-Ear, Nose, and Throat Journal Supplement 2 April 2005 Vol 84 No 4