Incidence, antimicrobial prescribing practice, and associated healthcare costs of paediatric otorrhoea in primary care in the UK: a longitudinal population study

Elliot Heward; Eleni Domzaridou; Sean P Gavan; Matthew Carr; Judith Lunn; John Molloy; Rachel Isba; Alastair D Hay; Jaya R Nichani; Iain A Bruce; Darren M Ashcroft

doi:10.3399/BJGP.2024.0053

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Treating paediatric otorrhoea
Elliot Heward

Published on: 01 April 2025
Treating paediatric otorrhoea
Arnold Zermansky

Published on: 25 March 2025

Published on: (1 April 2025)
Page navigation anchor for Treating paediatric otorrhoea
Treating paediatric otorrhoea
Elliot Heward, ENT Surgeon, Royal Manchester Children's Hospital
The authors thank Dr Zermansky for raising important questions on this topic.

It is commonly thought that when the tympanic membrane perforates the infection starts to resolve. This is the opposite to what Smith et. al. discovered; children with otorrhoea were more unwell compared to those with no otorrhoea.¹ Early treatment of children with otorrhoea can be justified.

The reported use of aminoglycoside topical antibiotics for children with otorrhoea needs further investigation. Topical aminoglycosides are a good option for treating otitis externa but this is a rare condition in young children. Otorrhoea is most frequently caused by a middle ear infection with a perforated tympanic membrane. ENT UK has produced guidance for the use of aminoglycosides with perforations.² It may be more appropriate to use a non-aminoglycoside drop such as ciprofloxacin.

Assessment of follow-up for children with otorrhoea was outside the scope of the paper due to coding limitations. Detailed information is required to determine the indication for and the clinical outcome at follow up. Anecdotally perforations heal if the middle ear infection resolves in a timely manner which would support adequately treating the initial infection. To the authors knowledge there are no guidelines outlining recommended follow-up for children with otorrhoea. It is therefore left to clinician discretion.

This study shows that the minority of children had repea...
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The authors thank Dr Zermansky for raising important questions on this topic.

It is commonly thought that when the tympanic membrane perforates the infection starts to resolve. This is the opposite to what Smith et. al. discovered; children with otorrhoea were more unwell compared to those with no otorrhoea.¹ Early treatment of children with otorrhoea can be justified.

The reported use of aminoglycoside topical antibiotics for children with otorrhoea needs further investigation. Topical aminoglycosides are a good option for treating otitis externa but this is a rare condition in young children. Otorrhoea is most frequently caused by a middle ear infection with a perforated tympanic membrane. ENT UK has produced guidance for the use of aminoglycosides with perforations.² It may be more appropriate to use a non-aminoglycoside drop such as ciprofloxacin.

Assessment of follow-up for children with otorrhoea was outside the scope of the paper due to coding limitations. Detailed information is required to determine the indication for and the clinical outcome at follow up. Anecdotally perforations heal if the middle ear infection resolves in a timely manner which would support adequately treating the initial infection. To the authors knowledge there are no guidelines outlining recommended follow-up for children with otorrhoea. It is therefore left to clinician discretion.

This study shows that the minority of children had repeated GP presentations (19.4%). Repeat appointments may be due to repeat perforations or untreated infections. Early treatment aims to prevent chronic discharge which causes hearing impairment at a crucial developmental age.

References

1. Smith L, Ewings P, Smith C, et al. (2010) Ear discharge in children presenting with acute otitis media: observational study from UK general practice. Br J Gen Pract doi: 10.3399/bjgp10X483148
2. Phillips JS, Yung MW, Burton MJ, Swan IR (2007) Evidence review and ENT-UK consensus report for the use of aminoglycoside-containing ear drops in the presence of an open middle ear. Clin Otolaryngol doi: 10.1111/j.1749-4486.2007.01532.x
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Competing Interests: None declared.
Published on: (25 March 2025)
Page navigation anchor for Treating paediatric otorrhoea
Treating paediatric otorrhoea
Arnold Zermansky, Retired GP, Leeds
Heward et al.’s population study of otorrhoea in children is consistent with everyday GP experience.¹

The management they report does have surprises. It is reasonable to prescribe amoxicillin on the basis that most will be associated with Pneumococcus or Haemophilus influenzae. On the other hand, it could be argued that once the drum has perforated (“Let the pus out.”) the infection is likely to resolve spontaneously, so the antibiotic is unnecessary, and the 28% who have no treatment has logic. The use of topical antibiotics (especially aminoglycosides with their ototoxicity) seems inappropriate and puzzling. Do these prescribers assume they are treating an otitis externa?

The issue the authors do not explore is follow-up. Is it overcautious to follow all patients to ensure that the perforation has healed? In fact, they almost always do heal. But if the majority of GPs do follow them a week or so later, then the number of consultations a year would not be 41,000 but of the order of 82,000, and more still if they are seen more than twice. So the NHS burden of the condition would be at least twice as high as the authors suggest.

The other phenomenon that isn’t clear from this paper is how many of the patients are repeat perforators. This group is a minority, but presents a real problem because some progress from earache to perforation in a few hours. If one believes that repeated perforation is likely to cause longe...
Show More

Heward et al.’s population study of otorrhoea in children is consistent with everyday GP experience.¹

The management they report does have surprises. It is reasonable to prescribe amoxicillin on the basis that most will be associated with Pneumococcus or Haemophilus influenzae. On the other hand, it could be argued that once the drum has perforated (“Let the pus out.”) the infection is likely to resolve spontaneously, so the antibiotic is unnecessary, and the 28% who have no treatment has logic. The use of topical antibiotics (especially aminoglycosides with their ototoxicity) seems inappropriate and puzzling. Do these prescribers assume they are treating an otitis externa?

The issue the authors do not explore is follow-up. Is it overcautious to follow all patients to ensure that the perforation has healed? In fact, they almost always do heal. But if the majority of GPs do follow them a week or so later, then the number of consultations a year would not be 41,000 but of the order of 82,000, and more still if they are seen more than twice. So the NHS burden of the condition would be at least twice as high as the authors suggest.

The other phenomenon that isn’t clear from this paper is how many of the patients are repeat perforators. This group is a minority, but presents a real problem because some progress from earache to perforation in a few hours. If one believes that repeated perforation is likely to cause longer term middle ear dysfunction (i.e. deafness), it is worth adopting a strategy, albeit not evidence-based, to strike early and prescribe antibiotics for the parent to have in stock to initiate at the very earliest sign of earache or fever.

Reference

1. Heward E, Domzaridou E, Gavan SP, et al. Incidence, antimicrobial prescribing practice, and associated healthcare costs of paediatric otorrhoea in primary care in the UK: a longitudinal population study. Br J Gen Pract. 2025;75(751):e113-e121. doi:10.3399/BJGP.2024.0053
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Competing Interests: None declared.

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