Purulent otitis media
Naturally, purulent otitis media is less common and is considered a subset of acute otitis media cases.
However, even in this case, the management and care are unique and therefore worth understanding.
What is purulent otitis media and how does it occur?
Purulent otitis media is an infection of the middle ear in which the eardrum is torn and pus spills into the ear canal and the eardrum area (see photo above).
Basically, what happens is that pus accumulates in the middle ear until the pressure causes a perforation in the eardrum.
I see two types of children with purulent otitis media:
- Those in whom nothing could have been done — without any preliminary symptoms, not even restlessness or fever, the child wakes up in the morning and there is a puddle of pus near their ear.
- Those in whom early diagnosis might have prevented the perforation — children who have been walking around with acute otitis media, do not see a doctor, or are not properly diagnosed. The pressure in the middle ear increases until the eardrum ruptures. In such children, who usually present with bulging of the eardrum before it perforates, there may have been an opportunity for immediate antibiotic treatment that could have prevented the rupture (though not always).
Clinically, it is important to emphasize that even if the child had symptoms consistent with acute otitis media — for example, fever and earaches — usually, after the perforation has occurred, the child will feel better. In fact, the release of pus relieves the pressure in the ear and usually leads to resolution of pain and fever.
What is the right treatment in case of purulent otitis media?
If the child sees the doctor after the perforation has already occurred and has not received antibiotics beforehand, the doctor will usually refrain from prescribing oral antibiotics. Since the child has already significantly improved, they are often no longer needed.
The doctor must examine the other ear — the one without perforation — to ensure there is no inflammation there as well.
It is important to recommend local treatment to help clear the pus — hydrogen peroxide at a concentration of 3%, applied three times a day. When hydrogen peroxide is dripped onto the pus in the canal, fermentation occurs, breaking down the pus and allowing it to drain out. That’s the goal. After the pus is broken down, the area around the opening of the canal can be dried and cleaned.
Sometimes, the doctor may recommend local ear drops. This is usually not necessary, except in cases where there is irritation of the auditory canal due to the pus.
Oral antibiotics should only be given if the child continues to have symptoms such as fever or earache, or if the discharge persists for more than two weeks.
Can purulent otitis media be contagious?
Purulent otitis media is a non-contagious infection, although I would not want the pus that drains from a child’s ear to come into contact with others. Therefore, the child can return to regular activity in their educational setting about 24 hours after the fever subsides, when they feel well, and when the amount of ear discharge is significantly reduced.
Can purulent otitis media cause hearing loss, and does it require expert advice from a pediatric ENT specialist?
Purulent otitis media is essentially the more severe form of acute otitis media. Even if the eardrum ruptures several times, it usually does not cause permanent hearing damage.
Don’t get me wrong—if, as a doctor, you see a child just before the eardrum perforates, you should administer antibiotics and try to prevent the rupture. But if the perforation has already occurred, further treatment is usually unnecessary.
However, recurrent purulent otitis media — for example, three episodes in six months or four in a year — warrants evaluation by a pediatric ENT specialist and consideration of ventilation tube surgery.
Managing chronic ear discharge (not the kind that occurs sporadically for a few days) is more complex and typically requires collaboration between a pediatrician and a pediatric ENT specialist.
In summary:
It is not pleasant to have your child walking around with pus draining from their ear. However, understanding the correct management can make the situation easier to handle.
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