Three patients came into the office with ear drainage. All three had different causes of the drainage, and all three were treated differently.
Nicholas was an 11-month -old male who had never had an ear infection. He had a fever for two days that was as high as 102 degrees. Mom denied any cough or runny nose, vomiting or diarrhea, or any other specific symptom. He was very fussy when the fever was elevated. But when he was given Tylenol or Advil and the fever came down, he seemed to perk up and was less fussy. The reason she brought him to the office was because during the night his fever reached 102.7 degrees and he was sweaty and irritable. She noticed that there was a dried, crusty discharge in the left ear that actually looked like dried pus. She was afraid that he might have had an ear infection and perforated the eardrum.
Amy was a 13-month-old who had a rough winter as far as ear infections go. In January it took two rounds of antibiotics to clear up that infection. The last round of antibiotics was accompanied by a five day course of steroids to get the fluid out of the middle ear space. Since September she had had four different ear infections, most of them requiring more than one course of antibiotics to clear.
The last round of antibiotics with the steroids cleared this ear infection. I was hopeful that since it was now April and we were getting out of the cold season, we might be able to buy some time during spring and summer to keep the ears clear until next winter. At that time Amy would be a bit bigger, and the anatomy of her middle ear and Eustachian tube might less likely become infected.
Mom was visibly disappointed when she came to the office. She knew the baby had another ear infection. “Amy has had a runny nose and cough for the past three days,” she said in a dejected tone. “And I was hoping to keep her off of antibiotics. But she was very fussy all night until around four o’clock a.m. at which time she stopped fussing and finally went to sleep. When she got up this morning I noticed a clear/cloudy drainage out of her ear and I knew it had perforated.”
Marcus was a two-year-old who had a number of ear infections starting when he was nine months old. It became worse between the ages of 12 and 18 months. Different antibiotics were tried, along with a short course of steroids to rid the middle ear of fluid, as it was clearly interfering with his hearing.
He was seen by an Ear, Nose and Throat specialist (ENT) who also tried conservative measures. But there was no way to clear the middle ear space. The fear was that it would greatly impact his speech development. At 19 months he had ear tubes inserted by the ENT. This is a fairly common procedure whereby a tiny tube is placed within the eardrum. This equalizes the middle ear pressure and will prevent infections. The tubes are temporary and typically fall out on their own. Some last a few months; others have to be surgically removed after a year or so.
Marcus had not had an ear infection since the tubes were inserted. According to mom he hadn’t even been sick. But she brought him in because she noticed him playing with his right ear. There had been some clear-looking drainage from that ear. He did not have cold symptoms, nor a fever. He seemed fine except for wanting to put his finger in the right ear. “I know that I’m probably overreacting,” she said in a convincing voice. “But I just want to be sure nothing is going on with his ears.”
Upon review, Nicholas did have a fever of 102.4 degrees when he was seen in the office. The thorough examination was 100 percent normal, even his ears. A urine exam was also normal. To explain the ear discharge, Nicholas had an abnormal amount of cerumen (ear wax) in both ears. His fever was high enough to MELT the cerumen. And that is what mom saw draining out of his ears. He did not need to go on antibiotics. Mom was instructed to continue what she was doing about fever control and to insure good fluid intake. The next day his fever broke, he developed a rash, and this cinched the diagnosis of roseola.
Amy was a different story. Her ear canal was full of purulent fluid and she was clearly uncomfortable. Upon examination a portion of the eardrum could be seen but it was red and angry looking. This was an ear infection that had perforated, causing the pus to spill onto the ear canal. As a result, she also had an outer ear infection, commonly known as swimmer’s ear. She was treated with an oral antibiotic for ten days as well as antibiotic drops for the outer ear infection. A follow-up visit with the ENT resulted in her being scheduled to have ear tubes inserted in a few weeks.
Marcus did not have a fever or any specific symptoms other than the ear drainage. Upon examination a copious amount of clear fluid was seen. The ear tube was visible and in its proper place. Mom wondered how the ear could have gotten infected since the tube seemed to be where it should be. One of two possibilities could explain it. The tube could have temporarily been plugged with ear wax, thus disabling it to function at all. Or he could have gotten water in the middle ear during his bath, even though he wears ear plugs. He was given as oral antibiotic as well as drops. A visit to the ENT the next day resulted in cleaning out the debris and fluid. Since the tube was functioning normally the oral antibiotic was no longer necessary. He was to finish five days of the drops for the outer ear canal. His re-check the following week showed the tube being clean and dry, and functioning normally.