Paediatrics: Disorders of the ear

Disorders of the ear

Otitis media

Infection of the middle ear is associated with pain, fever, and irritabil-ity. Examination reveals a red and bulging tympanic membrane with loss of normal light reflex. Occasionally there is acute perforation. Causative organisms include:

•   Viruses.

•   Pneumococcus.

•   Group A B haemolytic streptococcus.

•   Haemophilus influenzae.

Treatment is with broad-spectrum antibiotics (e.g. oral amoxicillin or co-amoxiclav) and analgesia. Decongestants may also help. Complicating mastoiditis or meningitis are rare. Recurrent ear infections can lead to secretory otitis media.

Secretory otitis media

•   This is a middle ear effusion without the symptoms and signs of acute otitis media. It is often the result of recurrent episodes of acute otitis media.

•   Duration often last months (chronic secretory otitis media) and the effusions may be serous (thin), mucoid (thick), or purulent.

•   Children, although asymptomatic, may be noticeably inattentive, or complain of hearing loss.

•   On examination the drum is retracted and does not move easily.

•   Fluid effusions may be visible behind the tympanic membrane, which appears opaque. Chronic (>3mths) secretory otitis media, particularly when associated with suspected hearing loss, needs referral to the audiology and otolaryngology (ear, nose, and throat/ENT) teams for further evaluation and possible treatment with myringotomy and insertion of typanostomy ventilation tubes (‘grommets’).

Otitis externa

•   Itching of the external ear canal is common in swimmers and after minor trauma.

•   There may be progressive pain and discharge.

•   Examination reveals an inflamed ear canal that may be oedematous.

•   Treatment is with suction clearance and a combined antibiotic (hydrocortisone 1% + gentamicin 0.3%) and steroid preparation applied topically.

Cholesteatoma

•   This is an erosive condition affecting the middle ear and mastoid.

•   It may lead to life-threatening intracranial infection.

•   Signs include offensive discharge, conductive hearing loss, vertigo, and rarely facial nerve palsy.

•   Urgent referral to the ENT team is required for surgery and antibiotics.

Acute mastoiditis

• Uncommon, but may follow an episode of acute otitis media. In the early stage symptoms are indistinguishable from those of acute otitis media, but may evolve to include intense pain, swelling, or tenderness over the mastoid process.

• The latter is due to acute mastoid osteitis and occurs when infection and destruction of the mastoid bony trabeculae has occurred.

• Clinical examination may also reveal outward and downward displacement of the pinna, and swelling of the posterior–superior wall of the external ear canal.

• Purulent discharge may also be present.

• Diagnosis is largely clinical, although CT scan is helpful. Urgent referral to the ENT team is required for IV antibiotic treatment. Mastoidectomy is sometimes indicated.

Foreign body impaction

• Parents may observe a child putting an object in the ear canal, which otherwise may take several days to come to notice.

• On examination with an auroscope, objects that are easily visible (and with a cooperative child) may be extracted using a hook.

• Use of forceps should be avoided as they tend to push the object further down the ear canal and may damage the tympanic membrane.

• Refer to ENT team.

Ear malformations

• Abnormal shape, orientation, or position of the ears should raise suspicions of an underlying congenital or inherited disorder or syndrome.

• Problems with hearing should also be suspected and evaluated.

• Referral to the clinical genetics team is required.

The following conditions are associated with ear malformations.

Low set ear position

• Turner syndrome.

• Noonan syndrome.

• Rubenstein–Taybi syndrome.

• Treacher–Collins syndrome.

Malformed auricles

• CHARGE association.

• Ehlers–Danlos syndrome.

• Di George syndrome.

• Down syndrome.