What is the suggested management for otorrhoea (discharge from the ear) in a 4-year-old child following tympanostomy tube (grommet) insertion?

From the Guidelines

For a 4-year-old with otorrhea (ear discharge) following grommet insertion, I strongly recommend starting with topical antibiotic ear drops containing ciprofloxacin or a combination of ciprofloxacin and dexamethasone, administered as 3-4 drops three times daily for 7-10 days, as this approach has been shown to be effective in treating uncomplicated acute tympanostomy tube otorrhea with minimal systemic absorption and reduced risk of antibiotic resistance 1.

Key Considerations

• The treatment targets the most common cause of post-grommet otorrhea, which is bacterial infection, and provides high local concentration of the antibiotic with minimal systemic absorption.
• The steroid component in the ear drops helps reduce inflammation, which is beneficial in managing the infection and promoting healing.
• It is essential to keep the ear dry during treatment by avoiding swimming and using ear plugs or cotton balls coated with petroleum jelly during bathing to prevent further contamination and infection.
• Cleaning the outer ear gently with a soft cloth, but avoiding inserting anything into the ear canal, is crucial to prevent pushing the infection further into the ear.

Management Approach

• If discharge persists beyond 10-14 days of treatment, shows blood, has a foul odor, or is accompanied by fever or significant pain, prompt reassessment by an ENT specialist is necessary to rule out complications or resistant infections.
• The use of topical antibiotic ear drops is preferred over oral antibiotics for uncomplicated cases, as it reduces the risk of systemic side effects and antibiotic resistance 1.
• Saline washout (irrigation) of the middle ear cavity during surgery may also be considered as a preventive measure against postoperative otorrhea, although its effectiveness compared to topical antibiotic drops needs further evaluation.

Evidence-Based Decision

The recommendation is based on the most recent and highest quality studies, including randomized controlled trials and systematic reviews, which support the use of topical antibiotic ear drops as the first-line treatment for uncomplicated acute tympanostomy tube otorrhea in children 1. This approach prioritizes the reduction of morbidity, mortality, and improvement of quality of life for the patient.

From the FDA Drug Label

The recommended dosage regimen for the treatment of acute otitis media in pediatric patients (from 1 to 12 years old) with tympanostomy tubes is: Five drops (0.25 mL, 0. 75 mg ofloxacin) instilled into the affected ear twice daily for ten days. The solution should be warmed by holding the bottle in the hand for one or two minutes to avoid dizziness that may result from the instillation of a cold solution. The patient should lie with the affected ear upward, and then the drops should be instilled The tragus should then be pumped 4 times by pushing inward to facilitate penetration of the drops into the middle ear.

For a 4-year-old patient with otorrhoea since grommet insertion, the suggested management is:

• Ofloxacin otic drops: 5 drops (0.25 mL, 0.75 mg ofloxacin) instilled into the affected ear twice daily for 10 days 2
• Administration:
  • Warm the solution by holding the bottle in the hand for 1-2 minutes
  • Lie with the affected ear upward
  • Instill the drops
  • Pump the tragus 4 times by pushing inward to facilitate penetration into the middle ear
  • Maintain the position for 5 minutes

From the Research

Suggested Management for Otorrhoea in a 4-Year-Old Since Grommet Insertion

• The management of otorrhoea in children with grommets involves various treatment strategies, including oral broad-spectrum antibiotics, antibiotic eardrops, or a combination of antibiotic(s) and a corticosteroid 3.
• Antibiotic eardrops with or without corticosteroid are more effective than oral antibiotics in resolving ear discharge at short-term follow-up, with moderate-quality evidence 3.
• The use of antibiotic eardrops, such as ciprofloxacin, has been shown to be effective in preventing postoperative otorrhoea and tube obstruction in children with grommets 4.
• A single application of topical antibiotic/steroid drops at surgery or a prolonged application of topical drops can reduce the rate of otorrhoea up to two weeks following surgery 5.
• There is limited evidence to support the use of water precautions, such as ear plugs or water avoidance, in preventing otorrhoea in children with grommets, with low-quality evidence suggesting a small reduction in the rate of otorrhoea with ear plugs 6.

Treatment Options

• Antibiotic eardrops (with or without corticosteroid) versus oral antibiotics:
  • More effective in resolving ear discharge at short-term follow-up 3
  • More effective in reducing the duration of ear discharge 3
• Antibiotic eardrops versus saline rinsing of the ear canal:
  • More effective in resolving ear discharge at short-term follow-up, but with moderate-quality evidence 3
• Eardrops containing a combination of an antibiotic and a corticosteroid versus eardrops containing antibiotics only:
  • More effective in resolving ear discharge at short-term follow-up, but with low-quality evidence 3

Considerations

• The risk of bias in the included studies was generally low to moderate, but the quality of the evidence was often limited by the small sample sizes and variability in the study designs 3, 5, 4, 6.
• The use of antibiotic eardrops may be associated with a risk of ototoxicity, although this was not found in the included studies 3, 5, 4.
• The cost and inconvenience of water precautions, such as ear plugs, may outweigh the limited clinical benefit in preventing otorrhoea in children with grommets 6.