The ins and outs of common ear problems

A 10-day course of antibiotics is still the norm for acute otitis media, despite growing interest in shorter courses. New recommendations favor topical antibiotics alone as first-line treatment for acute otitis externa, chronic suppurative otitis media, and tympanostomy-tube otorrhea.

Appropriate therapy is a significant concern in several common ear problems. Otitis externa (OE), for example, is associated with surprising differences in treatment between primary care practitioners and subspecialists. Treatment of eustachian tube dysfunction depends on the underlying cause. Yet by far the most controversy attaches itself to almost every aspect of the treatment of acute otitis media (AOM).

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Drugs mentioned in this article

Acetic acid 2%, propylene glycol diacetate 3%, hydrocortisone 1% otic solution (Acetasol HC, VoSol HC Otic) Acetic acid 2% in aluminum acetate, otic solution (modified Burow's solution) (Borofair Otic, Burow's Otic, Otic Domeboro) Amoxicillin (Amoxil, Trimox, Wymox) Amoxicillin/clavulanate (Augmentin) Carbamide peroxide Cefaclor (Ceclor) Ceftriaxone (Rocephin) Cefuroxime (Ceftin, Kefurox, Zinacef) Ciprofloxacin with hydrocortisone (Cipro HC Otic) Diphenhydramine Docusate sodium Erythromycin Erythromycin/sulfisoxazole (Eryzole, Pediazole) Fluconazole (Diflucan) Gentamicin, ophthalmic drops Guaifenesin/phenylpropanolamine HCl m-cresyl acetate (Cresylate) Mometasone furoate cream 0.1% (Elocon) Neomycin-polymyxin B-hydrocortisone suspension Ofloxacin, otic (Floxin) Pneumococcal 7-valent conjugate vaccine (Prevnar) Potassium iodide, supersaturated Sulfisoxazole (Gantrisin Pediatric) Tobramycin, ophthalmic drops (AKTob, Defy, Tobrex) Triethanolamine polypeptide (Cerumenex) Trimethoprim/sulfamethoxazole

ACUTE OTITIS MEDIA

AOM is the most common condition treated with antimicrobial agents in the United States. Data from the National Ambulatory Medical Care Surveys, which did not differentiate between AOM and otitis media with effusion (OME), showed that the number of office visits for AOM increased more than 2-fold between 1975 and 1990.

Treatment controversy

The medical community is divided on whether AOM should be treated at all, since it often is a self-limiting condition, or whether a 5-day course of medication is adequate. In some European countries, children older than 2 years with uncomplicated AOM are observed for 48 hours before antibiotics are initiated. Most US pediatricians still recommend using a standard 10-day course of antibiotics because they cannot predict which patients would benefit from antibiotic therapy and which would not.

Several studies have concluded that shorter courses of antibiotics are acceptable for children older than 2 years but less effective than longer courses in infants and younger children.^1,2 These studies, however, have been criticized for numerous shortcomings.^3,4

The bacteria responsible for most cases of AOM are Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae, with S pneumoniae accounting for up to half of all cases. Since most physicians do not perform tympanocentesis and culture the middle ear fluid, they prefer to assume the infection is bacterial and treat with antibiotics to prevent suppurative complications like mastoiditis and meningitis. An increase in the occurrence of mastoiditis has been reported in Germany, most of the cases involving children younger than 2 years who received no antibiotic treatment, treatment with a suboptimal agent, or treatment lasting only 5 days.⁵ A retrospective review involving 8 children's hospitals in the United States showed that the occurrence of mastoiditis caused by S pneumoniae remained stable from September 1993 to December 1998, despite increasing rates of antibiotic-resistant isolates. Most of the 34 cases were in children younger than 2 years who did not have a history of recurrent AOM.⁶

Pneumatic otoscopy makes the diagnosis

More important than the discussion about limiting or withholding antimicrobial therapy is the need to improve diagnostic skills in this area. Assessment of the appearance and mobility of the tympanic membrane (TM) is highly subjective. A physician skilled in pneumatic otoscopy is more likely to make an accurate diagnosis and avoid unnecessary or ineffective treatment.

AOM is characterized by the presence of middle ear effusion and the recent onset of signs and symptoms of local or systemic illness, such as earache, fever, irritability, sleep disruption, and upper respiratory tract infection (URTI) symptoms. In AOM, the TM is red or opaque and frequently bulging, and the malleus is obscured. There may be a layer of yellow fluid or pus behind the TM, and mobility is absent or markedly reduced on both positive and negative pressure. Sometimes the mobility of the TM is better seen by applying negative pressure—inserting the otoscope with the bulb deflated and then allowing it to fill.

Otitis media with effusion

Some clinicians confuse OME with AOM, which leads to the overuse of antibiotics and encourages multiple-drug resistance. OME is defined as the presence of fluid in the middle ear without signs or symptoms of ear infection. The American Academy of Pediatrics (AAP) and the American Academy of Otolaryngology recommend that antibiotics be considered only if the effusion lasts longer than 3 months and is associated with the presence of hearing impairment, or as a step before considering surgical placement of ventilation tubes.⁷ Too few physicians are following a consortium's clinical management algorithm for the management of chronic OME, according to a 1998 study and the consultants for this article.⁸ OME is often picked up during a routine physical examination and is usually asymptomatic, though the patient may complain of fullness or hearing loss. Otoscopy reveals an amber- or straw-colored TM with normal contour. The TM may be immobile. Audiometry may demonstrate a conductive hearing loss.

During the time that the serous otitis media is present, the child's hearing and thus learning are decreased. Six months of this situation amounts to about 30% of the child's total language-learning time and may lead to speech and learning problems. In the opinion of Dr Grossan, this possible effect is an indication for correction of the hearing loss. If clearing the sinus, shrinking the adenoids, and gentle autoinflation fail, he recommends myringotomy, removal of fluid, saline irrigation of the middle ear for thick fluid, and insertion of aeration tubes.

CDC guidelines

Recent recommendations from the CDC addressed the treatment of AOM in an era of pneumococcal resistance.⁹ First-line treatment should be amoxicillin, 40 to 50 mg/kg/d, up to 80 to 90 mg/kg/d. The CDC provided 3 alternatives for children who fail to respond to treatment within 3 days: cefuroxime, amoxicillin/clavulanate, and IM ceftriaxone.

There are, of course, other acceptable regimens with second- and third-generation cephalosporins for second-line therapy when amoxicillin fails. High-dose amoxicillin is indicated for a child in day care, who has had recent AOM, and is younger than 2 years. Another strategy is to use a combination: 40 mg/kg/d of amoxicillin/clavulanate and 40 mg/kg/d of amoxicillin bid. Follow up in 10 days if pain, fever, and "not acting well" persist.

Preventive measures

The CDC and AAP recommend universal vaccination with the pneumococcal 7-valent conjugate vaccine for the prevention of invasive pneumococcal disease in children up to age 23 months and in certain older children with chronic diseases or those who are at high risk. Although the vaccine may prevent only 10% of AOM occurrences, the more compelling reason to use it is the prevention of pneumococcal meningitis. The estimated annual cost of AOM in the United States is $3 billion. Prevention of even a small number of these cases would make a big dent in this public health problem.

Frequent pacifier use by infants older than 6 months increases the risk of ear infections. Suggest to parents that they take pacifiers away during playtime and allow toddlers to use them only when falling asleep.¹⁰ Advise parents that they might want to discontinue the pacifier if the child is having frequent AOM but it should not be withheld in newborns and infants. Other risk factors are exposure to secondhand smoke, day care in groups of 6 or more children, and bottle-feeding with the child in the supine position.

Some otolaryngologists favor irrigating the nose with saline solution in children with acute URTI to remove bacteria and prevent AOM; others think it risks spreading the infection to the sinuses and say that some patients consider it a form of torture. Both camps agree that parents should teach children to either not blow their nose because they often pop the ears too vigorously, or to do so extremely gently with both nostrils open. The same advice applies to inflating the ears and equalizing pressure after diving: hold the nose and very gently inflate the cheeks. Another way to clear the ears, if the person is adept, is to open the mouth wide and apply the tongue to the roof of the mouth and swallow.

Prescription guaifenesin/decongestant medications seem to work well as a mucolytic for some people, especially scuba divers. Even better is daily hydration with 8 to 10 glasses of noncaffeinated, nonalcoholic beverages. Gargling with salt water and performing gentle nasal irrigations with saline sprays also help, but not if acute sinusitis is suspected. For children with a runny nose, teach the mother the Proetz method of sinus irrigation: With the child in the mother's lap, head hyperextended, fill both nostrils with saline pediatric nose drops (without benzalkonium), then gently suction each side with a baby nasal syringe, while refilling the opposite side with saline till clear.

When to refer

Consider an otolaryngology consultation for a child with persistent AOM that has not cleared after 3 courses of an antibiotic, if a child has had recurrent AOM (3-4 cases within a 6-month period), if he or she has been on preventive antibiotics and is having breakthrough infections, or if 6 months of prophylactic antibiotics are undesirable. Because of concerns about promoting resistance, some pediatricians are referring more quickly to an otolaryngologist rather than attempting prophylaxis.

If you do decide to use a long-term antibiotic, make sure it is broad spectrum; avoid amoxicillin. Sulfisoxazole, a staple for years, is inexpensive and well-tolerated. Prescribe it twice a day at half the regular dose (50 mg/kg) during the winter months. Some prefer to use a single daily dose of the admittedly much more expensive amoxicillin/clavulanate, citing greater efficacy. There is no easy answer to the question of which patients would benefit from tympanostomy tubes and when.

A traumatic perforated TM must be checked for inner ear damage, especially a round window inner ear perforation. This is often accompanied by hearing loss and dizziness and requires an air and bone conduction test. If the loss is due to bone conduction, suspect inner ear trauma. If the loss is conductive—the air conduction is poor but the bone conduction is normal—the perforated eardrum is not an emergency and can be treated by the generalist. Avoid ear drops, and use antibiotics as indicated. (The specialist may attempt to bring the torn edges of the TM together as an office procedure.) A central perforation due to AOM or short-depth barotrauma can be managed by a primary care physician with oral antibiotics and regular follow-up for assessment of healing. If it is a peripheral, or an attic, perforation, refer to a specialist, especially if the audiogram is abnormal. Immediate referral is required when you do not see any changes such as excess cerumen or a red TM and the patient complains of sudden deafness.

OTITIS EXTERNA

Contrary to the practice patterns of many primary care offices, an American Academy of Otolaryngology-Head and Neck Surgery consensus panel recommends ototopical antibiotics as first-line therapy for the treatment of 3 common ear diseases: acute otitis externa (AOE), chronic suppurative AOM, and tympanostomy-tube otorrhea, in combination with external canal cleaning and dry ear precautions.¹¹ Data analyses from the 1993 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey showed that about 40% of adults and children received prescriptions for both systemic and topical medications.¹² The consensus panel concluded that in the absence of systemic infection or serious underlying disease, topical antibiotics alone are indicated and recommended the use of newer nonototoxic preparations such as the fluoroquinolone otic drugs ciprofloxacin with hydrocortisone and ofloxacin.

Neomycin-polymyxin B-hydrocortisone suspension is the most commonly prescribed topical medication, but it requires qid dosing, making compliance difficult, and can be ototoxic if it reaches the middle ear. Ophthalmic gentamicin or tobramycin drops have been commonly used for AOM with otorrhea, even in perforated ears. Both are ototoxic. The greatest danger occurs when aminoglycosides are used for more than 7 days or placed into dry middle ear spaces.¹³ Many people experience allergic skin reactions from neomycin. With the availability of the newer preparations, it is best to avoid the aminoglycosides and neomycin-containing preparations altogether.

The most common bacterial pathogens in AOE include Pseudomonas aeruginosa and Staphylococcus aureus; S pneumoniae, M catarrhalis, Proteus species, and Klebsiella species are infrequent or rare causes. The fluoroquinolone otic drugs, which have the advantage of being dosed twice a day, are effective against S pneumoniae, H influenzae, M catarrhalis, Staphylococcus strains, and Pseudomonas strains. The acetic acid preparations VoSol HC and Otic Domeboro have activity against some fungal organisms but no direct bactericidal effect other than by acidification.

The typical presentation of AOE is severe ear pain provoked by barely touching the ear or pressing on the tragus. These patients often require narcotic analgesics because the pain is so intense. Even chewing can be excruciating. Visualization of the ear canal clinches the diagnosis, since it often swells nearly shut. Profuse purulent drainage and skin debris from sloughed cells are also common. With worsening infection, fever and periauricular and cervical lymphadenopathy will develop. Otorrhea also can accompany AOM, but OE and AOM rarely coexist.

The first step is to cleanse the canal by either suctioning or debridement, preferably under microscopy. The accumulation of dead skin, wax, pus, and other debris feeds the infection, causes hearing loss, and increases irritation. One way to cleanse the ear is to use a very fine wire applicator (or a male urethral swab), spin some cotton on it, dip the cotton into hydrogen peroxide (some prefer VoSol HC or Otic Domeboro), pull the auricle up and back to straighten the ear canal, and very gently wipe the canal.

When the ear canal is too narrow for direct application of topical medication, use alligator forceps to insert a wicking material that has been made slippery by a cortisone ointment. Once it is in, use appropriate antibiotic ear drops. The wick allows the medication to enter the ear canal and the exudate to exit. Remove the wick after a few days, unless it has fallen out on its own, and debride. Advise the patient not to apply hot compresses, and prescribe an oral antihistamine to reduce painful swelling.

Chronic OE

The objective is to prevent chronic OE, which can cause canal stenosis, extreme pruritus, and dry flaky skin. Those with allergies, eczema, or chronic external ear irritation from a hearing aid are susceptible. Bacterial and fungal cultures may be warranted in certain areas of the country like the Pacific Northwest. Treatment includes a topical corticosteroid like mometasone furoate cream applied at the meatus and twice-daily fluoroquinolone drops. Explain the itch-scratch syndrome, and if you can trust the patient, have him or her apply the cream with a cotton swab while resisting the urge to scratch the ear with it. An antihistamine, especially if taken at bedtime, will reduce the symptoms and prevent scratching during sleep.

Fungal infection is promoted by the presence of moisture and warmth. Long-term antibiotic therapy, the absence of cerumen, and diabetes are predisposing factors. Because otomycosis may range in color from black to gray to yellow, or look like any other pus, culture or microscopy is helpful in cases that have failed to respond to topical antibiotics. Aspergillus infections account for more than 80% of the cases. Treatment includes removing external canal debris and altering the canal environment by applying acidifying agents and antifungal topical ear drops like m-cresyl acetate (warn patients about the odor). See the patient in a week to clean the canal again. For Candida infections, the use of oral fluconazole has met with mixed success.

Dry ear precautions

After patients have had a bout of OE, tell them to wait until they are completely asymptomatic and have followed dry ear precautions for 2 to 3 weeks before resuming swimming. Teach them not to get soapy water in the ear canal. Recommend placing several drops of baby oil or olive oil in the ear canal by dropper before showering or shampooing to prevent water touching the skin. Patients should start on an antihistamine like diphenhydramine or a topical corticosteroid cream the moment they feel any discomfort or irritation to prevent scratching the ear at night, a primary cause of infection. Educate patients about not trying to clean their own ears (see "The whole ball of wax").

 

The whole ball of wax Hearing loss is a frequent complaint in patients presenting at primary care offices, especially among older adults and those who wear hearing aids. Excess cerumen, which can be rock hard and adherent to the canal wall or tympanic membrane, is often the culprit. Methods for removal include ear drops, curettage, suction, and irrigation.1,2 When possible, recommend the use of ceruminolytic agents before the visit, and instill them at least 10 minutes before attempting removal. Curettage, which requires experienced hands to avoid traumatic bleeding from abrasion of the canal, can be difficult in a squirming patient. Stop any procedure if the patient complains of any discomfort or dizziness and prescribe ceruminolytic agents (4 drops qid) for at least 1 week before trying again. Carbamide peroxide, triethanolamine polypeptide, or the liquid stool softener docusate sodium all work well. To prevent recurrence, advise putting 1 to 2 drops of olive oil or baby oil in the ears before hair washing. The Reiner-Alexander ear syringe is portable and often found in nursing homes. Its disadvantage is that the pressure is difficult to control and may be too intense for the patient to tolerate. The DeVilbiss177 ear irrigator is easy to use and allows you to control the pressure and direction. Moreover, the tip is small and does not block the ear canal. An oral jet irrigator, which the manufacturer did not design for cerumen or foreign body removal, is convenient and fast but its use can be uncomfortable for the patient. The pressure can be too high, causing trauma to the stapes and cochlea by jamming the ossicles back and forth at 20 pulses per second. Perforations have been reported even at one third power. Other drawbacks include splash-back and poor visualization of the tip inside the ear. A special irrigator tip, developed by Murray Grossan, MD, a consultant for this article, is available that rocks the wax so that the water does not strike the tympanic membrane (TM) (see "Payment for cerumen removal"). Make sure the lighting is adequate and the water is about 37°C (98.6°F). Keep a finger or hand on the patient's head so that the instrument will move with the patient. Do not attempt irrigation if the eardrum may be perforated, if infection is present, or if there is any bleeding from a concussion or skull fracture. When necessary, use a number 5 suction tip to remove pus and cerumen. Leave blood alone, and wait as long as possible before cleaning the ear. Refer to an otolaryngologist if you suspect a previous perforation, or if the patient reports severe pain or dizziness during irrigation. A perforated TM may be associated with coexisting middle and inner ear injuries that require specialized follow-up care. If a patient tried the folk remedy known as candling, the wax should be removed by an otolaryngologist.   1. Grossan M. Safe, effective techniques for cerumen removal. Geriatrics. 2000;55:80-86. 2. Grossan M. Cerumen removal—current challenges. Ear, Nose, Throat J. 1998;77:541-542, 544-546, 548.

For tympanostomy-tube otorrhea, a vinegar/ boric acid drop or topical antibiotic can be used to keep the tube patent if the child is afebrile and not in pain. If the patient has pain or is tugging at the ears and has a fever, prescribe an oral antibiotic and a topical otic fluoroquinolone. For stubborn cases in which the child has had continuous drainage for weeks and has been on multiple antibiotics, obtain a culture and double-treat with the appropriate antibiotics.

EUSTACHIAN TUBE DYSFUNCTION (ETD)

The symptoms of ETD may include fullness and pain in the ears and, if persistent, hearing loss, tinnitus, and dizziness. An effusion may be present, and the TMs may look retracted. The tympanogram will show negative pressure (also known as a type C tympanogram). Treatment depends on the root cause, which may include congenital anatomic defects. Most people have an inflammatory condition of the nose or sinuses from chronic sinusitis or allergies. If corticosteroid nasal sprays and antihistamines offer no relief, consider ventilation tubes, especially in children who have immature eustachian tube function. Oral decongestants are of dubious benefit.

PRODUCED BY PETER D'EPIRO

REFERENCES

1. Kozyrskyj AL, Hildes-Ripstein GE, Longstaffe SE, et al. Treatment of acute otitis media with a shortened course of antibiotics: a meta-analysis. JAMA. 1998;279:1736-1742.

2. Hoberman A, Paradise JL, Cohen R. Duration of therapy for acute otitis media. Pediatr Infect Dis J. 2000;19:471-473.

3. Paradise JL. Short-course antimicrobial treatment for acute otitis media: not best for infants and young children. JAMA. 1997;278:1640-1642.

4. Cohen R, Levy C, Boucherat M, et al. Five vs 10 days of antibiotic therapy for acute otitis media in young children. Pediatr Infect Dis J. 2000;19: 458-463.

5. Hoppe JE, Koster S, Bootz F, et al. Acute mastoiditis—relevant once again. Infection. 1994;22:178-182.

6. Kaplan SL, Mason EO, Wald ER, et al. Pneumococcal mastoiditis in children. Pediatrics. 2000;106:695-699.

7. Quick Reference Guide for Clinicians: No. 12. Managing otitis media with effusion in young children. Arch Otolaryngol Head Neck Surg. 1994;120: 793-796.

8. Hsu GS, Levine SC, Giebink GS. Management of otitis media using Agency for Health Care Policy and Research Guidelines. Otolaryngol Head Neck Surg. 1998:118:437-443.

9. Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: Management and surveillance in an era of pneumococcal resistance—A report from the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatr Infect Dis J. 1999;18:1-9.

10. Niemela M, Pihakari O, Pokka T, et al. Pacifier as a risk factor for acute otitis media: a randomized, controlled trial of parental counseling. Pediatrics. 2000;106:483-487.

11. Consensus panel report. Use of ototopical antibiotics in treating 3 common ear diseases. Otolaryngol Head Neck Surg. 2000;122:934-940.

12. Halpern MT, Palmer CS, Seidlin M. Treatment patterns for otitis externa. J Am Board Fam Pract. 1999;12:1-7.

13. Bath AP, Walsh RM, Bance ML, et al. Ototoxicity of topical gentamicin preparations. Laryngoscope. 1999;109:1088-1093.

ARTICLE CONSULTANTS

DENNIS M. COOLEY, MD, pediatrician in private practice in Topeka and teaches medical students and residents of the University of Kansas School of Medicine, Kansas City.

MURRAY GROSSAN, MD, otolaryngologist in private practice in Los Angeles, Calif. His Web site may be accessed at http://www.ent-consult.com .

DOUGLAS HOFFMAN, MD, PhD, otolaryngologist in private practice in Crescent City, Calif. His Web site may be accessed at http://www.doctorhoffman.com .

 

The ins and outs of common ear problems. Patient Care 2002;6:56-71.