What is the best course of action for a 10-year-old patient with a history of ear tube (tympanostomy tube) insertion a few months ago, now presenting with right ear pain?

Management of Ear Pain in a 10-Year-Old with Tympanostomy Tubes

The first step is to examine the ear to determine if there is visible drainage (otorrhea) from the ear canal, as this dictates whether topical antibiotic ear drops are needed or if the tube is simply blocked.

Initial Assessment

The key diagnostic question is whether this represents acute tympanostomy tube otorrhea (drainage through the tube) versus a blocked/non-functioning tube or another cause of ear pain 1.

What to Look For on Examination:

• Visible drainage from the ear canal - indicates acute tube otorrhea requiring treatment 1, 2
• Tube patency - can the tube be visualized and is it open/functioning? 1
• Signs of tube complications - tube blockage, medial migration, or extrusion 1

Treatment Algorithm Based on Examination Findings

If Drainage is Present (Acute Tympanostomy Tube Otorrhea):

Prescribe topical antibiotic ear drops ONLY, without oral antibiotics, for uncomplicated acute tympanostomy tube otorrhea. This is a strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery 1.

Specific Topical Antibiotic Recommendations:

• First-line options: Ciprofloxacin or ciprofloxacin-dexamethasone (Ciprodex) ear drops 2, 3
• Dosing: Twice daily for 7-10 days 1, 2, 3
• Clinical cure rates: 77-96% with topical therapy versus only 30-67% with oral antibiotics 1, 2
• Why topical is superior: Higher drug concentration at infection site and better coverage of likely pathogens (Pseudomonas aeruginosa and Staphylococcus aureus) 1, 2, 3

Proper Administration Technique (Critical for Success):

• Have the child lie with affected ear upward 3
• Instill drops into ear canal 3
• "Pump" the tragus (flap in front of ear canal) 4 times to facilitate drops entering through the tube into the middle ear 1, 2, 3
• Maintain position for 5 minutes 3
• Clean drainage from ear canal opening with cotton-tipped swab dipped in hydrogen peroxide or warm water BEFORE applying drops 1, 2, 3

Water Precautions During Treatment:

• Keep ear dry and avoid swimming until drainage stops 1, 2, 3
• Use petroleum jelly-coated cotton to cover ear canal during bathing 3

When Oral Antibiotics ARE Indicated:

Oral antibiotics are unnecessary for most tube infections UNLESS 1, 2, 3:

• Child appears very ill or toxic
• Infection does not resolve after full 7-10 day course of ear drops
• Concurrent bacterial infection requiring systemic antibiotics exists
• Child is immunocompromised

If oral antibiotics become necessary, use amoxicillin or amoxicillin-clavulanate 1.

If NO Drainage is Present:

• Verify tube patency - if the tube is open and functioning, the infection should resolve without antibiotics 1
• If tube is blocked: The ear infection is treated as if the tube were not present; the blocked tube does not cause harm but also provides no benefit 1
• Use acetaminophen or ibuprofen for pain management while observing 1, 2

Red Flags Requiring ENT Referral:

Call the otolaryngologist if 1:

• Ear drainage continues for more than 7 days despite appropriate topical therapy
• Primary care physician cannot visualize the tube in the ear
• Child has hearing loss, continued ear infections, or persistent ear pain
• Drainage occurs frequently/recurrently

Common Pitfalls to Avoid:

• Do NOT prescribe oral antibiotics for uncomplicated tube otorrhea - this is specifically recommended against by guidelines 1
• Do NOT use topical drops for more than 10 days to avoid yeast infections of the ear canal 1, 2
• Do NOT fail to teach proper tragus pumping technique - this is essential for drops to reach the middle ear through the tube 2, 3
• Do NOT routinely prescribe prophylactic antibiotic ear drops after tube placement 1

Follow-Up Expectations:

• Child should improve within 48-72 hours of starting appropriate topical therapy 3
• If no improvement by 72 hours or drainage persists beyond 7 days, reassess for treatment failure 2, 3
• The surgeon should have examined the ears within 3 months of tube insertion and educated families about routine follow-up until tubes extrude 1