Author: Amy Pearson / Editor: Liz Herrieven / Codes: CAP24, PAP8 / Published: 02/06/2020
To the ENT novice there are a baffling number of terms that refer to problems with the ear… “otitis media” is that acute? Or suppurative? Or secretory? And where does glue ear fit into all of this and what are grommets anyway?! Here is hopefully a whistle stop tour into the terminologies, what’s important to know in an emergency setting and what to refer on…
Otitis media just means inflammation of the middle ear (and/or eardrum). This can be infective, which is acute or chronic otitis media, or not, which is otitis media with effusion. Otitis externa is inflammation of the ear canal.
Acute otitis media (AOM)
This is the typical ear infection that occurs in children. In fact it’s ridiculously rare to have otitis externa in children. AOM most commonly occurs in toddlers but can occur at any age. There may be a preceding URTI then ear ache (otalgia), a fever, possibly followed by a disgusting discharge from the ear. This may be bloody and usually the earache then improves as the pain is due to pressure on the ear drum. In the vast majority of cases the ear drum heals within 6 weeks once the infection has settled. When examining the ear the tragus is not tender and the drum may be red and bulging or obscured by pus.
The NICE guidelines for AOM state the condition is self-limiting and that it usually lasts for 3 days. Most people do not need antibiotics but children with otorrhoea or children under 2 with bilateral disease are more likely to benefit from antibiotics (amoxicillin first line). 1
Red flags relate to potential complications. Mastoiditis is usually pretty obvious although children may be systemically well due to a partial response to antibiotics from primary care. The post-auricular area is red and tender and the ear is pushed forwards. Mastoiditis needs admission under ENT with IV antibiotics, usually co-amoxiclav.
Mastoiditis can be associated with intracranial complications such as meningitis or abscesses, so if a parent states a child is not acting “quite right” then remember this. They may need imaging such as a CT head.
Otitis media with effusion (OME)
This is also called “glue ear”. It isn’t usually an acute problem so shouldn’t really need managing in the ED. It most often occurs in children and is very common with a fifth of 5 year olds having glue ear at any one time. Essentially it is mucous or snot behind the ear drum which forms because the Eustachian tube is not functioning properly. It may not cause any symptoms but can result in hearing problems (and consequently speech delay), poor balance (not dizziness) and sometimes predisposes to AOM.
On examination the child is well. The eardrum is intact but “dull”, this is a difficult call to make, particularly in children, unless you are looking at ears everyday.
OME almost always get better as children grow and many children don’t require any treatment. Because of this NICE guidelines recommend watchful waiting for 3 months before doing anything (with current waiting times this is easily achieved!)3. If children are still struggling after this time they may be offered grommets. These are tiny plastic tubes which are placed in the ear drum to ventilate the middle ear and stop the glue from forming.
The main reason such children would be seen in an acute setting is with an infected grommet. These present with often foul smelling discharge from the ear but children are usually systemically well and don’t have ear ache. People may mistake the discharge for the “glue coming out” but this is not the case. The best treatment is topical antibiotics. Sofradex or Gentisone ear drops can be used (yes even with a grommet or a perforation, there is an ENT consensus document supporting this2) but it may be less nerve-wracking to prescribe ciprofloxacin drops (eye drops if ear drops are not available) which have been shown to be just as effective.
Chronic otitis media
This basically means a permanent change to the ear drum and or middle ear. It includes perforations of the tympanic membrane and cholesteatoma. Perforations can get infected and tend to present like infected grommets: smelly discharge from the ear but no pain or systemic upset. Like infected grommets they are best managed with topical antibiotic drops.
Cholesteatoma was named incorrectly many years ago as it’s not in any way related to cholesterol or tumours. It’s essentially skin in the wrong place in the ear which continues to grow and shed (think sebaceous cyst!). It presents with a smelly discharge and hearing loss but again is not usually painful.
Unless these problems present to the ED with intracranial complications, which is occasionally the case, they can be given topical antibiotics and sent to ENT as an outpatient (via the GP if necessary).
As the name suggests this is infection of the external ear or ear canal. It almost exclusively occurs in adults and is also known as “swimmers ear”. Patients usually describe itching initially followed by pain, the ear feeling swollen or blocked and sometimes discharge. There is not usually an associated fever.
It can often be differentiated from AOM by the history. On examination unlike AOM the tragus and ear canal are very tender and the canal is usually swollen and may be filled with cheesy debris. Often the ear drum cannot be seen.
Risk factors for developing OE include diabetes, hearing aid use and lots of swimming. First line management is topical antibiotic drops, preferably with a steroid such as Sofradex, Cetraxal Plus or Gentisone HC. Sometimes the ear needs cleaning (microsuction) and it is worth referring to your local ENT clinic.
Reasons to refer acutely include spreading cellulitis or perichondritis. These are obvious as the pinna and/or face are swollen and red. Both conditions require admission and IV antibiotics. Patients may be systemically unwell.
Beware of the elderly diabetic patient with pain which is stopping them from sleeping. Sometimes otitis externa can spread into the bone causing skull base osteomyelitis. This is also called necrotising or malignant otitis externa. Patients usually have terrible ear ache and may have been using drops from the GP for weeks. If untreated this can lead to cranial nerve palsies and even death!
If in doubt, ENTSHO.com is a helpful website with pictures and advice on how to manage common ENT conditions and most ENT departments have emergency clinics where semi-urgent patients can be reviewed.