A 5 year old female with a PMH of chronic suppurative otitis media with bilateral tympanostomy tubes presents with left ear pain and blood tinged otorrhea from her left ear. She had been swimming in a pool for the past 4 days without ear plugs while on vacation. She is non-toxic appearing, afebrile, content, and comfortable appearing in triage.
On exam, she is found to have bilateral otitis externa with inflammation of the bilateral external auditory canals. Dried blood is present at the 12 'o clock position in the left ear canal. The tympanostomy tubes are in place bilaterally, The tympanic membranes are grey and not injected. There is pain with palpation of the tragus and pulling of pinna bilaterally.
She is started on ciprofloxacin suspension otic drops. Five drops BID in both ears for 7 days. She is discharged home with follow up to her pediatrician.
To keep things simple, when confronted with a pediatric patient with tympanostomy tubes who presents with an ear complaint, ask yourself, “When I look in the ear, do I see an O staring back at me?”
Out, Obstruction, Otitis. Your go-to treatments or interventions are either to
Remove the fully dislodged tube from ear canal
Treat with topical otic ear drops with Fluoroquinolone/steroid combination suspension drops.
Take Away #1 - Out
Displaced tympanostomy tube? This happens on its own. These tubes are meant to be in place temporarily (few months to 2 years). They will eventually dislodge and the TM is more likely to heal spontaneously the less time the tube has been in place. So if it is fully dislodged, remove it from the ear canal. If it working its way out, leave it alone and have the patient follow up with ENT.
Take Away #2 - Obstruction
Tympanostomy tubes allow for pressure to equalize across the TM in children who do not have fully matured musculature around the Eustachian tubes. When they develop a build up of mucus and bacteria, and then start to develop acute otitis media or otitis externa too often, they often need tubes to allow to pressure equalization and drainage of inflammatory/infectious material from middle ear.
These tubes can become obstructed with cerumen, blood, granulation tissue and prevent this equalization of pressure and drainage. Thus, dislodge the tissue and mucus with an ear speculum. When in doubt use topical fluoroquinolone/steroid combinations drops. The antibiotic addresses possible infection, the steroid helps breakdown granulation tissue, and the fluid helps dislodge other obstructing material.
Take Away #3 - Otitis
Patients with tympanostomy tubes still get both otitis externa and otitis interna. The most common presenting complaint is otorrhea. They may not have fever or ear pain if the tympanostomy is functioning properly. Otitis externa looks the same here as on other patients as well.
The treatment is fluoroquinolone suspension ear drops (Ofloxacin/Ciprofloxacin). You can use steroid containing combination drops as well, which helps reduce inflammation at the source. These topical FQ antibiotics are not ototoxic. They cover for the common bacteria for otitis interna/externa, and with topical application you avoid risks of systemic adverse effects.
Sean Boaglio, DO is a current third year resident at Stony Brook Emergency Medicine.
Reference(s):
MedScape: Typanostomy Tubes: Not magic bullet for AOM - https://www.medscape.org/viewarticle/730700
When Good Tympanostomy Tubes Go Bad - https://www.mdedge.com/pediatrics/article/38357/infectious-diseases/when-good-tympanostomy-tubes-go-bad
Edited by Bassam Zahid, MD