Paediatric Ear Pathology

DDx

• Acute otitis media (AOM)
• Serous otitis media
• Otitis externa
• Glue ear (chronic suppurative otitis media)
• Mastoiditis
• Grommets
• Cholesteatoma

Acute otitis media

• 2/3 of children have an episode by age 3
• 90% have an episode by school entry
• Peak prevalence 6-18 months
• Causes
  • Viral 25%; S. pneumonia (35%), H. influenzae (25%), M. catarrhalis (15%)
• If systemically unwell, consider other serious bacterial infection
  • Do not accept otitis media as sole diagnosis in sick febrile young child

• Examination
  • Handle of malleus, incus and light reflex poorly viewed
  • TM dull and opaque +- bulging
  • Yellow-grey TM
  • May have concomitant viral signs e.g. pharyngitis
  • A red TM alone is not OM

• Complications
  • Perforation
  • Febrile convulsions
  • Mastoiditis, suppurative labyrinthitis, meningitis/extradural abscess/brain abscess are very uncommon
  • Facial nerve palsy
  • Lateral sinus thrombosis
  • Benign intracranial hypertension

Management

• Most resolve spontaneously
• Antibiotics reduce pain at 24 hours in 5% of those treated
• Analgesia is most important
  • Topical 2% lignocaine drops
  • Paracetamol regularly
• Decongestants, antihistamines and steroids have not been proven helpful

Prognosis

• 70% have resolution within 72 hours without antibiotics
• 70% have persistent effusion after 2 weeks
• 10% have persistent effusion after 3 months

Serous otitis media aka otitis media with effusion

• Middle ear effusion without inflammation
• Serous effusion may persist for months following AOM
• Likely due to viral infection and/or persistent bacterial toxins in sterile environment
• Often causes conductive hearing loss
• Long-term effects on learning unclear
• Parental smoking is a risk factor
• Grommets can help (see next slide)
• High rate of spontaneous resolution over 3-6 months
• If >3 months = glue ear

Grommets

• Tympanostomy tubes indicated if bilateral OME >3 months with documented hearing issues
• Can consider if vestibular problems, poor school performance or ear discomfort also
• Can restore normal hearing but long-term effects on speech and language unclear

Hearing tests

• Weber test
  • Tuning fork to middle of forehead
  • If louder in one ear:
    • Conductive in that ear
    • Sensorineural loss in other ear
• Rinne test
  • Tuning fork to mastoid
  • When not heard any longer moved to outside of ear canal
  • If still heard, this suggests a sensorineural hearing impairment
  • If not heard, this suggests a conductive hearing impairment

Ruptured ear drum

• Heal spontaneously in 80% of cases
• Perforated AOM
  • Treat with oral antibiotics (not topical)
  • If treating concomitant otitis externa, add quinolone topical drops (not aminoglycoside)
• Water should be kept out of canal
• ENT referral if persistent or large perforation

Labyrinthitis

• Spread of AOM into cochlea or vestibular apparatus
• Sudden onset of vertigo and/or sensorineural hearing loss in AOM
• Chronic infections can cause damage to ossicles
• Consult ENT for myringotomy and expand antibiotic coverage

Chronic suppurative otitis media (CSOM)

• Perforated TM with otorrhoea >6 weeks
• Can occur with or without cholesteatoma
• Refer to ENT for possible myringotomy

Otorrhoea with tubes in situ

• Usually from external contamination if >6yo and treated with topical quinolones
• Usual otitis media pathogens in children <6yo so use oral antibiotics

Cholesteatoma

• Most common presentation is perforation with persistent drainage
• Ear drainage may be malodorous
• May see waxy white mass in middle ear
• Definition: Invasion of middle ear cleft by outer TM epithelium
  • Squamous epithelial cells arise from epithelium migrating through perforated TM
  • Dead keratin accumulates and becomes infected
  • Mass may be medial to TM in congenital cholesteatoma
• Can invade surrounding structures if not treated
• Requires ENT

Otitis externa

• Swimmer’s ear
  • Mostly Pseudomonas and Staphylococcus
• Chronic >3 months
• Furunculosis
  • Localised abscess in hair follicle in outer third of canal
• Otomycosis
  • Fungal
• Malignant
  • Usually immunocompromised
  • Pseudomonas often implicated and spreads to surrounding structures

• Examination
  • Pain with pinna/tragus manipulation or pressure
    • Helps to distinguish from otorrhoea from AOM with perforation
  • Check mastoid
  • Otomycosis appears like wet newspaper (grey/black)
• Peak incidence 7-12yo

• Treatment
  • Analgesia
  • Ear canal toileting
  • Keep ear dry
    • Can usually swim in 3-5 days
    • Acetic acid or isopropyl alcohol drops to prevent later
  • Topical otic drops (Sofradex)
    • Lie on side for 3-5 minutes after instillation
    • Use for 7-10 days (at least 5 days after cessation of symptoms)
    • Ear wicks if occluded canal
• Admit if malignant/necrotising otitis media

Mastoiditis

• Local infection of mastoid air cells in temporal bone
• 1/3 have preceding otitis media
• Otorrhoea >3 weeks may signify mastoiditis
• Pain is deep and behind ear
• May have conductive hearing loss, fever
• Tender over mastoid + erythema/swelling
• Same organisms as AOM + S. aureus/Pseudonomas

• Peak incidence in children <2yo
• CT of temporal bone without contrast
• Some authors recommend postponing CT in uncomplicated cases and only proceed if not responding to IV therapy
• IV Cefotaxime 50mg/kg QID +- mastoidectomy

Sudden sensorineural hearing loss

• Hypotheses
  • Atheromatous occlusion of vestibulocochlear blood supply
  • Viral neuronitis
  • Vestibular (acoustic) schwannoma
• May be associated tinnitus or vertigo
• Should have no focal neurology or otalgia

• Rx:
  • Many units give steroids (no evidence), antivirals (no evidence) and hyperbaric oxygen (some benefit)
  • MRI internal auditory meatus as outpatient
  • Audiometry and ENT follow-up
• Prognosis
  • 2/3 recover spontaneously

Foreign body in ear

• Persistently discharging ear in child should raise suspicion of FB
• Immediate ENT if button battery
• Various methods exist for removal
  • Insects: Water, olive oil or lignocaine to drown
    • Can shine light into ear to make insect come to surface or just let it drown
  • Direct vision with headlamp is key
  • Ear probe, alligator forceps or hook
  • Suction for smooth spherical objects

• Sedation may be required depending on age, maturity, difficulty
• Ketamine or general anaesthetic are most common
• Indications for ENT involvement
  • Failure to remove object
  • Evidence of significant trauma
  • Button battery
  • Penetrating foreign body

Last Updated on November 22, 2021 by Andrew Crofton