I was recently asked to write an article for INNEG which is medicolegal agency that I work with. I have written a short article on the problems with recurrent ear discharge (otorrhoea) and some of the diagnoses that we worry can be missed when this is not treated or investigated adequately. Article below or click the link on the image above.
The majority of children will have at least one and often more ear problems during childhood. This may take the form of an ear infection following a poolside holiday, glue ear causing deafness and requiring grommet insertion and in less common cases children may end up having episodes of repeated ear infections or otorrhoea. Most childhood ear infections are due to acute otitis media whereby the bugs that cause general winter-time coughs and colds ‘set up shop’ in the middle ear and cause the typical pain, fever and irritability followed by discharge of pus through a hole in the eardrum and often almost instantaneous relief from the symptoms.
A recent clinical negligence case that I was instructed to provide an expert opinion on involved a 7 year old girl who had been seen by her GP on several occasions with a discharging ear. On each of these occasions, the girl was prescribed antibiotic drops and appeared to make a good recovery. She was, however, referred to the local audiology department due to Mum’s concern about hearing loss. A subsequent examination identified glue ear for which he was referred to the local ear, nose and throat department to discuss further management options. For a variety of reasons, the girl was seen again in the audiology department and GP practice but did not see an ENT doctor until approximately 18 months later. At that time, she was noted to have some wax in her left ear and a moderate hearing loss on that side. She was listed to come in for grommets and adenoidectomy in order to ventilate the middle ear and drain out the offending fluid but at the time of surgery she was noted to have some polypoidal tissue arising from the superior (attic) region of the ear. This was biopsied and the results of the biopsy and a subsequent CT scan led to the diagnosis of cholesteatoma for which she underwent a modified radical mastoidectomy operation which left her with a long term conductive hearing loss in the left ear.
Cholesteatoma is collection of keratinous debris that collects in a retraction pocket of the tympanic membrane. It can be filled with keratin and appear quite dry or can be associated with active bacterial infection leading to profuse malodorous discharge. Cholesteatomas are potentially dangerous because of their potential to incite resorption of bone leading to intra-temporal or intra-cranial complications such as meningitis and brain abscesses in very rare cases. As well as the serious complications, cholesteatomas, when left untreated, can cause persistent, offensive otorrhoea (ear discharge) which most people find troublesome. The aim of surgery is to remove the cholesteatoma disease and render the ear safe, clean and dry.
The NICE guidelines on glue ear outline the presentation of glue ear with a history of repeated ear infections or earache, recurrent upper respiratory tract infections or frequent nasal obstruction and hearing difficulty. The claimant in this case suffered from all of these symptoms and although it may have seemed appropriate that she had been diagnosed with glue ear, there is an overlap in the presentation and symptoms of glue ear and cholesteatoma. The claimant in this case had predominantly unilateral ie left sided ear discharge. Otorrhoea can be seen in glue ear but is less common than the hearing loss that is seen. Persistent and unilateral discharge should have prompted the search for another cause. In addition the hearing loss that was diagnosed was moderate to severe whereas the typical level of hearing loss in glue ear is mild. A misinterpretation of the claimant’s symptoms as being due to glue ear led to a delay in the diagnosis of the underlying cholesteatoma and a delay in the appropriate, curative surgery.
Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery. 7th Edition 2008
NICE Clinical Guideline CG60