Ear infections and trauma

Contributed by Dr Jean Watkins, a retired GP in Hampshire

Otitis media
Acute otitis media is common in general practice. Children under five are frequently affected and it often occurs in association with an upper respiratory tract infection.

The child usually presents with pain, fever, irritability and sometimes vomiting. Examination reveals a red, bulging eardrum or actual purulent discharge.

Many cases will resolve spontaneously with analgesics only. If an antibiotic is necessary, amoxicillin is the drug of choice. It may be most beneficial in the under-twos, those with bilateral otitis media, high fever, purulent discharge complications, co-morbidities or if systemically unwell.

Foreign body in the ear

The advice that 'nothing smaller than the elbow should be put into the ear' is worth repeating. However, children in particular may still insert beads, paper and other foreign objects.

Small items may be successfully removed by syringing the ear but anything of vegetable origin may absorb the water and swell. Attempts at removal with forceps may further damage the canal or push it deeper into the meatus.

It is best to refer any case in which the object cannot be easily removed to the ENT department.

Mastoiditis


Thanks to prompt use of antibiotics in acute suppurative otitis media, spread of the infection to the mastoid process is seen less often.

The patient presents with increasing earache, deafness in the affected ear, fever (particularly in children) and swelling and tenderness over the mastoid process behind the ear. Infants may offer less specific symptoms of irritability, fever and being off their food. The area may be inflamed and the pinna pushed forward.

The infection is usually responsive to broad-spectum antibiotics, which may need to be given IV.

Scrumpox



This man had recurrent episodes of a blistering rash on the pinna of his right ear since his rugby days. Close contact sports such as rugby or wrestling offer the possibility of trauma at points of skin-to-skin contact and transmission of the herpes virus. The problem is then likely to recur at the same site.

Early treatment with aciclovir helps to speed recovery and the patient should be supplied with a prescription to take at the first sign of recurrence. Those with an active episode should be excluded from sports. For repeat recurrences long-term prophylactic aciclovir may be offered.

Ear piercing

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As many as 35 per cent of those with pierced ears have had one or more complications. Despite sterile technique in most cases, transmission of hepatitis B, although rare, has occurred.

This patient recently had her ears pierced. She was concerned about the discharging granulomatous lesion that had developed at the point of entry of one of the rings. She was advised to remove the ring and started on ciprofloxacin in an attempt to stop further spread of infection. The patient was offered excision of the lesion if it persisted.

Auricular perichondritis



Auricular perichondritis may develop as the result of trauma, lacerations or spread from poorly controlled otitis externa.

With piercings in the upper part of the pinna, infection and perichondritis may follow within a few weeks.

The infecting organism is usually Staphylococcus aureus, Streptococcus pyogenes or Pseudomonas aeruginosa. The patient presents with inflammation, swelling pain and tenderness of the auricle. The patient may also be febrile.

Early treatment with antibiotics is important to avoid perichondrial abscess or necrosis of the cartilage.

Nickel allergy



There seemed little doubt that the eczematous reaction on the ear lobe of this patient was due to an allergy to the nickel earring that she had been wearing for the previous two weeks. Nickel allergy is a common problem that may develop after a single or repeated exposure.

If allergy is suspected, all contact with nickel should be avoided in the future. If there is doubt about the diagnosis allergen patch testing can be carried out.

This patient had already removed the offending earring and was offered a topical corticosteroid to help to settle the reaction.

Split ear lobe



With the use of large, heavy earrings, the piercing is likely to enlarge and lengthen. In time, it is not unusual for the earring to fall out or be accidentally pulled out by an excited child or if caught in clothing.

Repair involves surgical correction. Although there are risks of infection and scarring, the results are normally good.

The ear can be re-pierced after about six weeks but the patient should be advised not to return to wearing long heavy earrings in the future.

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