What is the diagnosis and treatment for chronic otitis media (middle ear infection) with otorrhea (discharge) in a pediatric patient?

From the Guidelines

Chronic otorrhea in a child should be initially treated with careful ear cleaning followed by topical antibiotic drops, such as ciprofloxacin 0.3% or ofloxacin 0.3%, administered as 3-4 drops into the affected ear twice daily for 7-10 days, as recommended by the most recent guidelines 1. The treatment approach for chronic otorrhea in children involves a step-wise management plan, starting with topical antibiotic therapy. The choice of antibiotic drops is crucial, with quinolone drops being preferred due to their effectiveness against common pathogens such as Pseudomonas aeruginosa and Staphylococcus aureus. Some key points to consider in the management of chronic otorrhea include:

• Careful ear cleaning before administering topical antibiotic drops to ensure the medication reaches the site of infection
• Use of topical antibiotic drops approved for use with tympanostomy tubes to avoid potential ototoxicity
• Limiting topical therapy to a single course of no more than 10 days to minimize the risk of antimicrobial resistance and other adverse effects
• Considering oral antibiotics, such as amoxicillin-clavulanate, if discharge persists despite appropriate topical therapy, particularly if there are signs of more extensive infection
• Referring persistent cases to an otolaryngologist for consideration of tympanoplasty or other surgical interventions, as chronic otorrhea can lead to hearing loss and developmental delays if left untreated 1. It is also important to note that the management of chronic otorrhea should be guided by the most recent clinical practice guidelines, which emphasize the importance of careful diagnosis, targeted treatment, and regular follow-up to ensure the best possible outcomes for children with this condition 1.

From the FDA Drug Label

The recommended dosage regimen for the treatment of chronic suppurative otitis media with perforated tympanic membranes in patients 12 years and older is: Ten drops (0.5 mL, 1. 5 mg ofloxacin) instilled into the affected ear twice daily for fourteen days. Chronic Suppurative Otitis Media in patients 12 years and older with perforated tympanic membranes due to Proteus mirabilis, Pseudomonas aeruginosa, and Staphylococcus aureus.

For a child with chronic otorrhea, the dosage of ofloxacin (OTIC) is not explicitly stated for patients under 12 years old. However, for patients 12 years and older, the recommended dosage is ten drops (0.5 mL, 1.5 mg ofloxacin) instilled into the affected ear twice daily for fourteen days 2.

• The indication for ofloxacin (OTIC) includes Chronic Suppurative Otitis Media in patients 12 years and older with perforated tympanic membranes 2. Since the child's age is not specified, and the label does not provide a dosage for children under 12 with chronic suppurative otitis media, a conservative clinical decision would be to consult the label for Acute Otitis Media in pediatric patients or other relevant conditions, but the provided information does not directly answer the question for a child under 12.

From the Research

Causes of Chronic Otorrhea in Children

• Chronic otorrhea in children is often caused by the same organisms that cause otitis media, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 3.
• In older children, drainage from tympanostomy tubes may involve organisms that colonize the external auditory canal, such as Pseudomonas aeruginosa and Staphylococcus aureus 3.

Treatment of Chronic Otorrhea in Children

• Ofloxacin otic solution has been shown to be effective in the treatment of acute otorrhea in children with tympanostomy tubes, with a cure rate of 84.4% 4.
• Topical ofloxacin has been compared to oral amoxicillin/clavulanate and found to be as efficacious in the treatment of otorrhea caused by acute otitis media in patients with tympanostomy tubes 3.
• Other topical antibiotics, such as ciprofloxacin, have also been shown to be effective in the treatment of chronic suppurative otitis media, with a slight increase in resolution of ear discharge compared to systemic administration 5.

Safety and Efficacy of Topical Antibiotics

• Ofloxacin otic solution has been shown to be safe and well-tolerated in children, with no reports of ototoxicity or serious adverse events 4, 6.
• Other topical antibiotics, such as mupirocin and clotrimazole, have also been shown to be safe and effective in the treatment of tympanostomy tube otorrhea, with no reports of ototoxicity or serious adverse events 7.

Comparison of Topical and Systemic Antibiotics

• There is limited evidence available to compare the effectiveness of topical and systemic antibiotics in the treatment of chronic suppurative otitis media, but some studies suggest that topical administration may be more effective in achieving resolution of ear discharge 5.
• The choice of antibiotic and route of administration should be based on the specific needs of the patient and the severity of the infection.