Acute otitis external
Diffuse inflammation of the external auditory meatus, of bacterial or fungal origin, favored by maceration, trauma to the ear canal, the presence of a foreign body, an eczema, psoriasis.
Clinical signs:
– Itching of the ear canal or ear pain often intense and increased traction flag; feeling of “blocked ears”; clear or purulent discharge or no flow
– Otoscopy:
• diffuse redness and swelling or infected eczema of the ear canal
• check for foreign objects
• normal eardrum if visible (the examination is often hindered by the swelling, pain, secretions)
– Removal of the foreign body if present.
– Pain: paracetamol and / or ibuprofen PO (page 29).
– Local treatment (about 5 to 7 days):
Remove skin debris and secretions using a dry cotton swab or a dry cotton wick. possibly apply gentian violet 0.5% using a cotton swab once a day.
Washing / aspiration syringe with 0.9% sodium chloride is to consider that if the eardrum was clearly visualized and it is intact (non-perforated).
In other cases, ear wash is against-indicated.
Acute otitis media (AOM)
acute inflammation of the middle ear, of viral or bacterial origin, very common in children under 3 years, rare in adults.
The main bacteria responsible for acute bacterial otitis media are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and in older children, Streptococcus pyogenes.
Clinical signs :
– Earache Quick Setup (infants: crying, irritability, insomnia, refusal to suck / to eat) and flow (otorrhea) or fever.
– The association of other symptoms such as runny nose, cough, diarrhea or vomiting is common and may lead to misdiagnosis of the need to examine the eardrums.
– Otoscopy: bright red eardrum (or yellow if ready to break) and pus effusion, externalized (otorrhoea on perforated eardrum) or not (bulging eardrum and opaque).
The association of these signs with an earache or fever confirmed the diagnosis of AOM.
Note :
The following signs are not enough to make the diagnosis of AOM:
• An isolated redness, without bulging or perforated ear drum, towards a viral ear infection in a context of infection of the upper airway or may be due to the tears and cries of the child or a high fever.
• The presence of bubbles or effusion behind an intact eardrum without signs / symptoms of acute infection, corresponds to otitis media with effusion (WHO).
– Possible complications, especially in children at risk (malnutrition, immunodeficiency, ear malformation) are chronic suppurative otitis media, and more rarely, mastoiditis, brain abscess and meningitis.
Treatment:
– In all cases :
• Treat fever and pain: paracetamol PO, page 26.
• Ear washes are cons-indicated in cases of eardrum perforation or if the eardrum is not correctly displayed in the examination. No indication on the ear drops instillation.
– Indications of antibiotic therapy:
• Antibiotic therapy is prescribed at the outset in children less than 2 years, children with signs of severe infection (vomiting, fever> 39 ° C, severe earache) and children at risk of unfavorable changes (malnutrition, immunodeficiency, ear malformation).
• For children:
1) If the child can be re-examined after 48 to 72 hours it is best to wait before prescribing an antibiotic because evolution can be spontaneously favorable and short symptomatic treatment of fever and pain may be enough . An antibiotic is prescribed if the clinical picture worsens or does not improve after 48 to 72 hours.
2) If the environment does not allow to review the child is prescribed antibiotics immediately.
• For children under antibiotic therapy: ask the mother to return if the fever or pain persists after 48 hours of treatment.
– Choice of antibiotic therapy:
• Amoxicillin is the first-line treatment:
amoxicillin PO: 80 to 100 mg / kg / day divided in 2 or 3 doses for 5 days
• Amoxicillin / clavulanic acid is used in second intention, in the event of treatment failure. A failure is defined as persistent fever and / or pain after 48 hours of treatment.
Amoxicillin / clavulanic acid PO (the dose is expressed in amoxicillin): 45 mg / kg / day divided into 2 or 3 doses for 5 days
The persistence of a single flow, without fever or pain in a child whose clinical condition has also improved (regression general signs and local inflammation) does not justify a change of antibiotic therapy. Clean carefully and locally the outer pipe with a dry cotton until the end of the flow.
• Azithromycin or erythromycin should be reserved for the few patients allergic to penicillin as treatment failures (resistance to macrolides) is frequent.
azithromycin PO
Children over 6 months: 10 mg / kg / day once daily for 3 days
erythromycin PO
30 to 50 mg / kg / day divided in 2 or 3 doses for 10 days
Chronic suppurative otitis media (SCAT)
chronic bacterial infection of the middle ear with a perforated eardrum and a persistent purulent discharge.
The main causative organisms are Pseudomonas aeruginosa, Proteus sp, staphylococci, other gram-negative and anaerobic.
Clinical signs:
– Purulent drainage for more than 2 weeks, often associated with hearing impairment or deafness, no pain or fever
– Otoscopy: perforated eardrum and purulent discharge
– Complications:
• Think superinfection (AOM) for fever with ear pain, and treat accordingly.
• Consider mastoiditis in case of quick installation of high fever with poor general condition, severe earache and / or painful swelling behind the ear.
• Think of a brain abscess or meningitis in case of disturbance of consciousness, neck stiffness, focal neurological signs (p. Ex. Facial paralysis).
Treatment:
– Remove secretions with a dry cotton swab or a dry cotton wick and apply ciprofloxacin (ear drops): 2 drops 2 times / day to dry up the flow (max 4 weeks. ).
– Complications:
• Chronic mastoiditis: it is a medical emergency requiring immediate hospitalization, prolonged antibiotic treatment covering the germs of OMCS (ceftriaxone IM PO ciprofloxacin 10 days + 14 days), non-traumatic wound care (cleaning the duct ) and optionally a surgical treatment. If the patient has to be transferred, the first dose of antibiotics before transfer.
• Meningitis