Acute otitis externa in children, Emergency Department

• Infective: 
  1. Bacterial – Pseudomonas Aeruginosa, Staph. Aureus and proteus commonest
  2. Fungal – Aspergillus, candida (often after previous use if ear drops) 
  3. Viral – Herpes Simplex and zoster
• Reactive: 
  Often seen in patients with eczema, psoriasis, seborrhoeic dermatitis

• Presents with itching, discharge, hearing loss and pain, which may be severe.
• Look for symptoms of head and neck infection elsewhere e.g. tonsillitis/sinusitis
• Predisposing factors include humidity, swimming, hearing aids, trauma, eczema/psoriasis, narrow ear canals (e.g Downs Syndrome), Diabetes Mellitus
• Ask about previous otological history and identify any possible allergens/irritants
• Important to determine if any preceding symptoms of acute otitis media

• External canal may be erythematous, narrow, oedematous, and tender.
• It may be impossible to visualise the tympanic membrane.
• Discharge – green/offensive may suggest pseudomonas, mucoid may suggest middle ear pathology, or fungal hyphae may be present.
• May be pain on moving pinna and tragal tenderness.
• There may be post-auricular tenderness localised to a palpable lymph node.
• The presence of a perforation suggests the primary pathology may be in the middle ear.
• Look for any evidence of spreading cellulites/erysipelas.

Beware bony tenderness over the mastoid, with fluctuance and displacement of the pinna down and forwards suggest mastoiditis.

• Otitis externa
• Otitis Media and otitis externa
• Otitis Media with perforation (unable to see tympanic membrane)
• Consider foreign body with secondary infection Investigation
• Get an ear swab for microbiology if recurrent infection or failure of a prior treatment.

• Analgesia.
• Topical antibiotic/steroid drops. Gentisone HC is the departmental choice. Clotrimizole drops used for fungal infections. No evidence of benefit with oral antibiotics in uncomplicated acute otitis externa.
• If patient returns after treatment with Gentisone HC with same problem, swab ear and arrange ENT review.
• If you are uncertain if TM perforation present – safe to use topical aminoglycosides for up to 2 weeks in a patient with a discharging ear and a perforation of the tympanic membrane.
• If canal very swollen and instillation of drops not possible – consider referral to ENT for wick insertion. Suction clearance may also be of benefit if copious debris in canal.
• If evidence of spreading facial cellulites/erysipelas then refer to ENT for consideration of admission and intravenous antibiotics.
• Early reassessment desirable – can be by GP or arrange ENT review if recurrent infection or failure of a prior treatment.

• Regular analgesia – pain may be severe
• Advice on the correct instillation technique of drops – lie head on pillow with ear facing upwards, insert drops, massage the tragus, then lie in the same position for 5-10 minutes before moving.
• Advice to keep ear dry
• Treatment should be continued for about 1 week after resolution.