August 2000
ATLANTA - More than 1 million tympanostomy tubes are placed annually, and between 10% and 50% of all children with tympanostomy tubes will have at least one episode of otorrhea. Still, identifying the cause of otorrhea may be complicated.
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Recent medical history is important when assessing a child with otorrhea. "Try to illicit a history of associated events, such as trauma, previous ear disease, surgery and particularly in the summer months, frequency of swimming," said Michelle Mary Fitzpatrick, MS, RN, clinical nurse specialist in otolaryngology at the University of Michigan Medical Center in Ann Arbor, Mich. "Knowledge of associated signs and symptoms is also helpful, such as a history of rhinorrhea. If the child has a runny nose, and [has] an ear tube in place, that child is very likely to have otorrhea as well, since the upper airway mucosa is interconnected."
Fitzpatrick said the oral pharynx and tonsils should also be assessed.
"Have they been chronically infected? Are they enlarged? Be sure to take into consideration the anterior/posterior tonsillar diameter as well," said Fitzpatrick, who spoke here at the 21st Annual Nursing Conference on Pediatric Primary Care. "Look for the presence of postnasal drip on the posterior oral pharynx."
  |
--- Tympanostomy tube in situ with inferior granulation
tissue (top). Chronic suppurative otitis media through perforation
(bottom).
PHOTOS COURTESY OF ANN MARIE RAMSEY, MSN, RN,
CPNP
Examining the otorrhea may be especially helpful
because the characteristics of the otorrhea may provide an indication as to the
potential cause. "Purulent otorrhea is light yellow to green in color, looks
like pus and is highly suggestive of bacterial etiology," said Fitzpatrick. "It
contains white blood cells, debris and bacteria, and it's usually the result of
an infectious process. Keep in mind that the presence of otorrhea suggests an
open tympanic membrane in the form of a perforation or the presence of a
pressure equalizing tube, because there are no mucous glands in the external
auditory canal. Bloody otorrhea suggests either trauma or, in the presence of
equalizing tubes, it may be secondary to the presence of granulation
tissue."
"The external auditory canal should be inspected for the presence of macerations, abrasions or granulation tissue," she said. "General appearance of the tympanic membrane should be considered as well. Key inspection points include the characteristics of the drum. Keep in mind that an erythematous tympanic membrane reddened does not always equal infection. The tympanic membrane has the normal red reflex, which is the result of vascular congestion, which can be from crying or fever."
Presence of pus is a primary consideration for a diagnosis of suppurative otitis media (OM). "Otorrhea can vary in character and quality," said Ann Marie Ramsey, MSN, RN, CPNP, of the University of Michigan Hospitals in Ann Arbor. You may see a white to clearish type of otorrhea, ranging to a yellow green. Some children actually have a very fluorescent quality to their otorrhea."
Additionally, a foul odor may be present. However, children will otherwise be asymptomatic. "They're running around; they're playing," Ramsey said. "The only reason the parents know there's a problem is because they see the otorrhea."
Otitis externa should be considered as part of a differential diagnosis. Pain is a hallmark feature. "That's going to be one of the key points to differentiate between suppurative OM and otitis externa," Ramsey said. "Suppurative OM isn't generally associated with pain."
Patients may also complain about severe itching, and edema may be present. However, drainage may be present. When it does appear, drainage typically will be crusty and yellow, Ramsey added.
A differential diagnosis of granular myringitis should also be considered. Drainage is usually scant and may appear more serous or bloody. Although more common in children with tympanostomy tubes, it may occur in children without them as well.
Besides otorrhea, "you'll also notice that there's a pinkish, cotton candy appearance to this tissue," said Ramsey, who also spoke at the nursing conference. Granular myringitis can actually progress to the point of forming a polyp.
Bullous myringitis is another consideration and is characterized by the vesicles that form on the surface of the tympanic membrane.
"This is extremely painful," Ramsey said. "The patients will complain of very intense pain. You frequently will see this copresenting with an upper respiratory infection or a lower respiratory infection. The drainage typically is serosanguineous and bloody." However, "after the patients start to drain, they typically report that they feel better. In these cases, you may or may not have middle ear effusion."
According to a recent article by a consensus panel of experts in otolaryngology published in a recent Otolaryngology-Head and Neck Surgery,"... in the absence of systemic infection or serious underlying disease, topical antibiotics alone constitute first-line treatment for most patients with chronic suppurative otitis media, otitis externa and tympanostomy tube otorrhea."
The authors further recommend that topical preparations be selected on the basis of the suspected bacteriology of the disease process and the potential risks and benefits of the topical preparation. The fluoroquinolone class of antibiotics, which include ciprofloxacin (Cipro, Bayer) and ofloxacin have demonstrated excellent otorrhea resolution rates and no ototoxicity in several studies.
For more information:
- Ramsey AM, Fitzpatrick MM. Management of the child with a draining ear in the primary care setting. Session 103. Presented at the 21st Annual Nursing Conference on Pediatric Primary Care. March 29-April 1, 2000. Atlanta.
- Hannley MT, Denneny JC, Holzer SS, et al. Use of ototopical antibiotics in treating three common ear diseases. Otolaryngol Head Neck Surg. 2000;122(7):934-40.
- Kiris, Muzaffer, Berktas, et al. The efficacy of topical ciprofloxacin in the treatment of chronic suppurative otitis media. Ear Nose Throat J. 1998;77(11):1-4.
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