Recalcitrant Otorrhea 'After the Tubes'

In a retrospective review conducted at a pediatric otolaryngology clinic, out of a total 1,242 patients who underwent ear culture between 1996 and 2003, 166 patients (119 with otitis media, 41 with otitis externa, and 6 with both) aged 16 days to 18 years (mean 4 years) were found to have fungal organisms. The proportion of fungus-positive cultures increased dramatically in the years following the availability of the fluoroquinolone drops, from just 4.2% of 356 cultures obtained during 1996–1998 to 18.2% of the 457 cultures done during 1999–2001 (Int. J. Pediatr. Otorhinolaryngol. 2005;69:1503–8).

The most common of the fungi were Candida albicans (43% of the 166), Candida parapsilosis (23.5%), and Aspergillus fumigatus (21%). Although reporting of medications was inconsistent, the authors estimated that the patients had previously received an average of 1.7 oral antibiotics and 1.1 ototopical agents before the culture was taken. Infection resolved in all the patients with treatment, which included clotrimazole topical and tolnaftate topical in 27 patients each, fluconazole in 25, acetic acid alone in 14, and topical plus fluconazole in 10. The thinking is that the use of broad-spectrum quinolone drops may be promoting the emergence of fungus by eliminating the colonizers in the external ear canal, thereby allowing the fungus to grow. This doesn't imply we should stop using quinolone-containing otic solutions, but I do think we need to be aware of the possibility and culture the middle ear in a child who still has otorrhea after 5–7 days of treatment.

Of course, we all know that prevention is the best medicine.

A group from Turkey recently published a comparison of 1 mL intraoperative isotonic saline irrigation, postoperative antibiotic treatment (sulbactam/ampicillin 25 mg/kg for 5 days), postoperative ofloxacin drops (twice a day for 5 days), or placebo in 280 children (mean age 5.9 years) undergoing bilateral ventilation tube insertion because of serous otitis media during 2000–2004 (Am. J. Otolaryngol. 2005;26:123–7).

At 2 weeks post surgery, purulent otorrhea was observed in 15.7% of the saline group, 14.2% of those who received prophylactic oral antibiotics, and 8.6% of the topical antibiotic group, all significantly lower than the 30% rate among the controls. It appears that saline irrigation of the middle ear prior to tube placement offers a low-cost intervention for reducing early post-tympanostomy tube otorrhea.