Chronic Drainage

After topical or oral antibiotics, or both, have been given for initial treatment, the patient is reexamined at 10 days. If drainage is greatly improved but not yet resolved, the same antibiotics can be continued for another 10 days. However, if drainage is no better, several causative factors must be considered.

First, chronic drainage can persist because the bacteria are resistant to the antibiotic. Frequently this implies that the infection is caused by Pseudomonas aeruginosa, which is resistant to all oral antibiotics except ciprofloxacin. Moreover, even though most topical antibiotics will cover Pseudomonas, sometimes drainage is so profuse that the drop cannot penetrate the tube to the middle ear. If the ear is still draining without improvement after initial antibiotic treatment, the drainage should be cultured to determine whether Pseudomonas infection is present. Preliminary results often are known in 36 h.

After the culture is obtained, the ear canal is cleaned and the tube suctioned. Often pulsating pus quickly exudes again through the tube to fill the ear canal. One helpful additional treatment is to irrigate the canal with 2% acetic acid before instilling the drops. The mechanical flush of the canal gets rid of most of the drainage and debris long enough for the antibiotic drop to reach the tube and middle ear. A simple inexpensive wash can be prepared by mixing equal parts of white vinegar and tap water, boiling the solution for 5 min for sterilization, and preserving it at room temperature. A small bulb syringe is used to flush the solution into the canal with the ear turned downward. The ear is then dried off and turned upward, and the drops are instilled for 5 min. These steps are repeated three times daily. The patient is reminded about dry ear precautions.

Another change of treatment for Pseudomonas is oral ciprofloxacin hydrochloride (Cipro). Ciprofloxacin is routinely used in adults, but its use is more controversial in children. Initial publications suggested that bone growth in children might be impaired by ciprofloxacin. However, these data were based largely on animal research, and many clinicians now believe that ciprofloxacin can be given safely to children without impairing bone growth.1 The dose of ciprofloxacin is 250 to 500 mg bid, depending on body weight.

After the canal is carefully cleaned down to the tube, the relationship among the tube, eardrum, and middle ear mucosa is determined. An operating microscope is very helpful for this, and the child should be restrained as needed to get a clear view of the tube. If granulation tissue surrounds the tube, if myringitis is present, or if the tube lumen is completely obstructed with mucosal disease, removing the tube right away is the most helpful step. Any foreign-body irritation is removed, and topical drops then penetrate better into the middle ear through the residual myringotomy/perforation. The very same topical and oral antibiotics that failed to help in the initial treatment with the tube in place, often quickly clear the infection now with the tube out. Thus, ciprofloxacin can be avoided in children. Removing the tube requires no anesthesia in the youngest children, general anesthesia in older children, and local anesthesia in adults.

Sometimes the tube appears in good position, no granulation surrounds the flange, and no mucosal disease obstructs the lumen. In this case the culture report determines the treatment. If the causative organism is Pseudomonas and the patient is an adult, oral ciprofloxacin 500 mg bid is added to topical drops. If the organism is Pseudomonas and the patient is a child, the fastest, safest treatment still is tube removal, even though the tube appears normal. The patient then is scheduled to return for follow-up examination in another 10 days. If the tube has been removed, the eardrum usually is healed and the active infection is resolved. Residual effusion may be present in the middle ear. The patient is seen again in several weeks depending on hearing in the opposite ear. If middle ear effusion becomes chronic, a new tube is reinserted.

Probably 80% of acutely draining PE tubes clear with initial treatment, and another 80% of chronically draining tubes clear with anti-Pseudomonas treatment with or without tube removal. The remaining few patients, probably less than 5% of all patients with chronic draining PE tubes, have underlying localized mucosal or temporal bone disease, or upper respiratory immunologic, allergic, or bacterial disease that perpetuates tube drainage. A careful history and examination at the first office visit usually identifies these patients. Does the patient have "allergy" or "sinus" disease, especially inhalant allergy with rhinitis and sinusitis? Does the patient have frequent bronchitis or pneumonia, perhaps associated with sinusitis and recurrent otitis? Consider immunoglobulin G (IgG) subclass deficiency, immotile cilia syndrome, iatrogenic immuno-suppression, human immunodeficiency virus (HIV) infection, tuberculosis, and Wegener's granulomatosis. Does chronic ear pain suggest neoplasm, particularly squamous cell carcinoma? Has the patient received radiation therapy within recent months? Is there evidence of osteoradionecrosis? If any of these underlying disorders is suspected, appropriate consultation and studies are indicated, including consultation for allergy, immunodeficiency, and recurrent respiratory disease; computed tomography (CT) for sinusitis, neoplasm, or osteoradionecrosis; magnetic resonance imaging (MRI) as indicated clinically; and tissue culture for tuberculosis and histology for malignancy and Wegener's granulomatosis.

If the initial history and examination do not suggest any of these problems, and appropriate antibiotics have been given based on the culture and sensitivity report, yet drainage persists despite removal of the PE tube, the middle ear mucosa is assumed to be irreversibly diseased. Treatment consists of intra venous antibiotics or chronic ear surgery, or both. Hospitalization and intravenous antibiotics are appropriate for patients, particularly children, who have chronic middle ear mucosal disease, and who have persistent fever, pain, or other symptoms suggesting possible complication of infection. The child is admitted for several days of intravenous antibiotic(s) based on culture, with consultation with a pediatric infectious disease specialist. If there is prompt clinical improvement within several days, surgery is postponed indefinitely and home intravenous antibiotic therapy (HIVAT) is continued as an outpatient. If there is no clinical improvement, tympanomastoidectomy is performed, middle ear tissue is sent for histology and culture, and antibiotics are continued as an outpatient after recovery from surgery.

Management of the draining PE tube is usually straightforward; antibiotics, dry ear precautions, and occasional tube removal will cure almost all patients. Persistent chronic drainage, however, requires evaluation for underlying disease, intravenous antibiotics, and/or surgery. Table 34-1 provides a summary of management.

TABLE 34-1

Management of Acute and Chronic Draining PE Tubes

Acute drainage Etiology

Upper respiratory infection/inflammation Water/other contamination of ear canal Treatment

Canal cleaning and examination of PE tube Topical/oral antibiotics Dry ear precautions Chronic drainage (persists after initial treatment) Etiology

Resistant bacterial infection

Different causative organism (fungus, tuberculosis) PE tube foreign body reaction/myringitis Underlying upper respiratory/temporal bone disease Sinusitis

Osteoradionecrosis Neoplasm Underlying systemic disease

IgG subclass deficiency/immunosuppression Inhalant allergy Irreversibly diseased mucosa (serous mastoiditis) Treatment

Dry ear precautions

Different antibiotic based on culture and sensitivity Different antimicrobial therapy to cover fungus, tuberculosis Sinus/temporal bone CT

Allergy/immunology workup as indicated clinically Tube removal and topical/oral antibiotics Intravenous antibiotics Chronic ear surgery

Hughes—CHAPTER 34

1. Sabella C, Goldfarb J. Editorial. Fluoroquinolone therapy in pediatrics: where we stand. Clin Pediatr 1997;36(8):445-448

First conceived by Politzer and Cassells1 in 1868, ventilating tubes were not popular until the 1950s, when Armstrong2 introduced them in 1954. The tympanostomy tube has since become one of the most commonly employed yet contentious devices in modern medicine. In children, otitis media is the most frequent reason for nonwell visits to a physician. Often it is recurrent and medically refractory. Vent tube placement has become an important weapon in the otolaryngologist's war on this problem. In fact, myringotomy with vent tube placement has become the most common operation in children requiring general anesthesia in the United States. Enthusiasm for the procedure has been moderated, however, in both otolaryngologists and pediatricians by complications, the most common of which is post-tympanostomy otorrhea (PTO).

Although vent tube placement is a safe and effective treatment strategy that has significantly reduced the incidence of chronic mastoiditis and acquired cholesteatoma, PTO occurs within a range of 3.1 to 37.9%. Luxford and Sheehy's3 reported incidence of 21% is typical. This literature is well summarized by Goldstein et al.4 Higher rates of PTO have been associated with large-bore vent tubes (41% and 69% in two studies5'6). PTO is not thought to be more common in patients who have undergone prior myringotomy with intubation.7 In children with cleft palates, reflux of nasopharyngeal secretions into the middle ear has been associated with higher rates of PTO (67%).8,9 Patients undergoing concomitant adenoidectomy do not represent higher PTO risks.10

PTO can occur early, at 2 weeks after surgery, or at some time later. The etiology of both scenarios is different.11 Early PTO is thought to be a function of the underlying disease or to represent surgical contamination. Early PTO is clearly related to the conditions in the middle ear cleft at surgery.12 Dry or serous effusions are rarely associated with PTOs, whereas mucoid or mucopurulent effusions and/or middle ear mucosal disease is statistically correlated with PTO. An enormous literature has been dedicated to surgical PTO prophylaxis. Although contradictory, consensus appears to refute the efficacy of drop therapy or canal preparation. Younger children appear to be more susceptible than older children.7,10 Late PTO is more frequently associated with extrinsic contamination of the middle ear and otitis media associated with upper respiratory infection or allergic disorders.11 Late PTO occurs more commonly during the summer months with water contamination.13 Intubation abolishes the air cushion of the middle ear. In young children, this may make bacterial reflux from the nasopharynx and eustachian tube more problematic.14 Adenoidectomy does not appear to influence late PTO.

PTO bacteriology has been reviewed by Schneider.15 In young children under age 3 years, isolates were similar to those found in acute otitis media, except that Hemophilus influenzae is more common than D. pneumoniae. The presence or absence of concurrent upper respiratory infection is significant in choosing a treatment strategy. In children older than age 3 years and in whom infectious causes are more common, Pseudomonas sp. is a common isolate (in 25%). Gram-positive species (Staphylococcus) are even more common (in 45%), many of which are penicillin resistant, even in nonhospital communities (80%). PTO management in this population is somewhat more problematic.

Most cases of PTO arise from extensive contamination of the middle ear through the open tube. The risk of otorrhea after tympanostomy tube placement is three times higher than after myringotomy alone.

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