Condition 136 Fever, irritability, ear discharge

Alexander is a 2-year-old boy who presents to the general practice office with an acute febrile
illness. He has had a runny nose for a few days and has become febrile and irritable over the past 24
hours. He did not sleep well the previous night and has vomited twice today. Shortly before
presentation his mother noticed a discharge from his right ear. There is no past history of significant
illness.

Examination findings:
On examination he is febrile (temperature 38.8 °C) and flushed. There is clear rhinorrhoea.
The right ear canal is full of pus. The left eardrum is intensely red and bulging as illustrated. He has
no neck stiffness.
There are no other abnormal physical signs.

TASKS:
1. Explain the likely diagnosis to the parent.
2. Explain to the parent the management you would recommend.

You have obtained all the relevant findings on history and examination.

APPROACH
From the history and examination, most likely your child has a condition called acute otitis media.
This is a common childhood illness, and is often preceded by a viral upper respiratory tract infection.
I will explain to you the condition, and if you have any questions along the way, please don’t hesitate
to stop me and I will explain it to you again.

The ear is made up of three parts. The outer ear includes the part you can see and the canal that
leads to the eardrum. The middle ear is separated from the outer ear by the eardrum and contains
tiny bones that amplify sound. The inner ear is where sounds are translated to electrical impulses
and sent to the brain.
Any of these three parts can become infected by bacteria, fungi or viruses.

A middle ear infection usually happens because of swelling in one or both of the eustachian tubes,
the tubes which connect the middle ear to the back of the throat. The tubes let mucus drain from
the middle ear into the throat.
A cold, throat infection, acid reflux, or allergies can make the eustachian tubes swell. This blocks the
mucus from draining. Then, viruses or bacteria grow in the mucus and make pus, which builds up in
the middle ear.

Sometimes, if the pressure from the fluid build-up gets high enough, it can rupture the eardrum,
with fluid draining from the ear. This spontaneous drainage of the middle ear after perforation of
the ear drum/tympanic membrane leads to relief of pain and resolution of fever. Do not be stressed,
the hole in the tympanic membrane is usually small and heals spontaneously within a few weeks in
the majority of cases. Most children do not have significant, long-term deficits in hearing, but we
could arrange for a hearing test following healing of the drum to check this.

Ear pain is the main sign of a middle ear infection. Kids also might have a fever and trouble eating,
drinking, or sleeping because chewing, sucking, and lying down can cause painful pressure changes
in the middle ear. They are also often seen
tugging at the ear and are fussy and cry more than usual.
I will give your child Panadol for the relief of pain, and high dose oral antibiotics to clear out the
infection. Usually acute otitis media will resolve without antibiotics but the presence of a purulent
discharge from the right ear and a bulging left eardrum in your child necessitates its use in this case.
We could also get a sample of the discharge and send it for culture and sensitivity. You also can do
gentle ear toilet, which is with a cotton bud, remove excess discharge from right ear, so that the ear
is kept dry.
I will give you reading materials for further insight, and I will arrange a review with you in one week
for further examination and inspection of the right eardrum. If the perforation does not heal
spontaneously, I will refer you to the ENT specialist. If your child is not eating well, not feeding well,
drowsy, then see me immediately. When the drum has healed, we could do a hearing check in 8
weeks time.

KEY ISSUES
 Management of acute otitis media in childhood.
 Ability to achieve rapport with anxious parent, who is blaming herself as she feels her inaction
has compromised her child's hearing permanently.

IMPORTANT POINTS FROM THE COMMENTARY

 While this scenario addresses otitis media, a common condition in young children, the
important issue to be addressed as well is the guilt the parent feels (inappropriately) that her
inaction has caused her child to be permanently deaf. This is not the case and spontaneous
perforation is quite common. Reassurance that this can occur in any case of otitis media, and
often is beneficial in that it relieves symptoms of pain and discomfort immediately should be
emphasised. By the end of the consultation, these fears of the parent should be allayed by
appropriate reassurance.
 Perforation does not necessarily mean major damage to the tympanic membrane, which
generally heals completely without any hearing loss or damage to the middle ear. In this case,
there is evidence of significant infection in the other ear and antibiotics are considered
appropriate in this case. Gentle ear toilet with cotton buds to remove excess discharge is all
that is necessary for the right ear and antibiotic drops are not necessary. The parent should be
cautioned about vigorous cleansing of the external canal.
 Most cases of otitis media in young children have a viral aetiology and antibiotic therapy is
usually unnecessary. Otitis media is usually part of a generalised upper respiratory tract
infection. While the condition usually resolves completely without any sequelae, it is
appropriate to review for any complications and to arrange for a hearing test, especially if the
parents feel that his hearing does not seem normal following the illness. They should be
counselled to present him again if this is the case.
 If antibiotics are to be used, it is important to ensure that an appropriate drug is used in
adequate dosage.