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Am Fam Physician. 2001;63(7):1426-1427

Otorrhea, defined as drainage from the ear, can be acute (lasting six weeks or less) or chronic (lasting more than six weeks). This common problem can be caused by benign or serious conditions.

Sabella reviewed the management of otorrhea in infants and children. Acute otorrhea is usually a result of acute otitis media or otitis externa, or a postoperative complication of tympanostomy tube placement. Acute otitis media can cause spontaneous rupture of the tympanic membrane, allowing purulent material to drain into the external ear canal. The microbiology of these cases is similar to that of otitis media without perforation. The most common organisms associated with an acutely perforated tympanic membrane are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Group A streptococcus, a relatively rare cause of otitis media, appears to be associated with a higher rate of acute perforation and more rapid injury to the tympanic membrane.

Otitis externa can cause acute otorrhea, accompanied by ear pain and severe edema along with the drainage. This infection is more common in the summer months and is associated with swimming and prolonged exposure to water. Differentiating otitis externa from acute mastoiditis may be difficult because of severe ear pain and the inability to visualize the tympanic membrane. The absence of postauricular erythema and tenderness in otitis externa helps with differentiation. Gram-negative bacteria, especially Pseudomonas aeruginosa, cause most cases of otitis externa.

Otorrhea is the most common complication of tympanostomy tube placement. The insertion of ototopical drops at the time of surgery appears to be effective in reducing the rate of otorrhea. Acute otorrhea in a patient with a tympanostomy tube may represent acute otitis media or water contamination from the external canal. Aspirating material from the middle ear through the tympanostomy tube will help in identifying the causative organisms.

Acute otorrhea associated with otitis media with perforation can be treated with oral antibiotics. It is helpful to obtain a specimen for culture directly through the perforation before initiating treatment. The use of ototopical agents in the treatment of otitis media with perforation is controversial, but the newer fluoroquinolone otic solutions are not known to be ototoxic and may have a role in these cases. When otorrhea continues for 10 days despite the use of oral antibiotics, culture of the drainage from the perforation site is important in guiding antibiotic choice. The specimen can be obtained using a spinal needle attached to a tuberculin syringe. Cleaning of the ear canal may also be required. Otorrhea that continues beyond 14 days requires a careful examination for cholesteatoma, neoplasm or intracranial abnormalities. Treatment of otorrhea in children with tympanostomy tubes should be guided by stain and culture of purulent material. The use of ototopical agents such as ofloxacin and irrigation are usually sufficient, although oral antibiotics are often used. Otitis externa can be treated with gentle suction using hypertonic saline and instillation of 2 percent acetic acid. Antibioticcorticosteroid combination otic drops may be helpful if canal wall inflammation is severe.

Chronic otorrhea is most commonly secondary to chronic suppurative otitis media (CSOM), although cholesteatoma, foreign body, granuloma, immunodeficiency or neoplasm may also cause it. CSOM is chronic inflammation of the middle ear and mastoid with a nonintact tympanic membrane and otorrhea. The most common organisms involved in this condition include P. aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis, viridans streptococci and S. pneumoniae. Evaluation includes a complete examination and a culture of organisms from the middle ear. Initial management includes the use of ototopical agents and aural toilet. This may require frequent visits to a physician. There is little place for oral antibiotics in the treatment of CSOM because of the lack of an oral antibiotic effective against P. aeruginosa in children. If otorrhea continues for an additional two weeks despite treatment, intravenous anti-pseudomonas agents, such as ceftazidime, may be useful. Surgical intervention is reserved for patients who fail all medical therapies.

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