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So, if you have a situation where:

   - a patient had significant ear pain that has now resolved
   - there is a purulent discharge from the ear
   - no history of swimming, manipulation, or trauma (or other risk
   factor for OE) of the auditory canal
   - no pain with manipulation of the pinna or insertion of the otoscope
   speculum

Would you tell the parents that the "boil" is now draining and that no
further treatment was necessary?

I personally doubt that most parents would believe you or accept your
explanation.  I think it is certainly appropriate to explain this to them,
but doubt that most parents would accept not getting a prescription for
antibiotics (either topical or oral).  I probably would write the script and
encourage the parents to refrain from antibiotics for at least 24 hours.  If
the patient continues to improve, then leave it at that, but if the pain
recurs, then start the antibiotics.  Whether the parents actually wait that
long is up to them.

John Lee, MD


On 1/12/07, David Spiro <[log in to unmask]> wrote:

> Like much in medicine, we have a tendency "to act" rather than "observe"
> because doing "something" makes us feel better as physicians. For example,
> prescribing anitbiotics for acute otitis media at the time of the first
> visit rather than applying a wait and see approach.
>
> In regard to pus from the external canal, many of these cases are
> perforated tympanic membranes from acute otitis media. Most children with TM
> perforation are now pain-free and the "abscess" has been drained, naturally.
> In these cases of uncomplicated perforated AOM I am unaware of any research
> indicating the need for antibiotics, systemic or topical (although we were
> all trained to give one or the other or both).
>
> In cases of acute, non-complicated otitis externa (much of this is based
> on history as perforated AOM or OE can present with pus in the canal
> obscuring the tympanic membrane) what is the reason to suck out the pus? I
> admit it does feel good to do so in any body cavity as a doctor but we might
> put our children-patients through an unnecessary procedure? If this
> procedure is painful and does not provide the physician with an answer that
> will alter the outcome maybe it would be best to prescribe topical
> antimicrobial therapy and call it a day, saving pus extraction for another
> body cavity!
>
>
> David Spiro, MD
> Portland, OR
>
>
> >>> "Cordle, Randy" <[log in to unmask]> 01/12/07
> 5:16 AM >>>
> I do in many bad cases.  Many times with bayonet suction or small
> feeding tube you do not need to numb the canal but if it is very swollen
> and no space is there for the tube then you need to numb the canal
> itself with injections with a 30g needle.  If you use ice or a tiny dab
> of EMLA it helps but it still hurts for a couple seconds.  Once
> suctioned a wick can be placed.  I tie a string through the wick and
> leave it behind the ear. This prevents digging in the days to come if it
> doesn't fall out and allows one to know if it came out or not more
> easily.  As with everything, having the right tools is key; wear a
> headlamp and have an assistant.
>
> I hope this helps,
> Randy Cordle MD
>
> -----Original Message-----
> From: Pediatric Emergency Medicine Discussion List
> [mailto:[log in to unmask]] On Behalf Of PED-EM-L automatic
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> Subject: PED-EM-L Digest - 10 Jan 2007 to 11 Jan 2007 (#2007-9)
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> There is 1 message totalling 28 lines in this issue.
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> Topics of the day:
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> 1. otitis externa
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> ----------------------------------------------------------------------
>
> Date:    Thu, 11 Jan 2007 07:48:36 -0800
> From:    don zweig <[log in to unmask]>
> Subject: otitis externa
>
> I wonder how many of you ever suction pus out of an ear canal in a pt
> with OE and if so how you do so and do you use any block (anest)?
> It is clearly recommended to do so but i don't believe i have ever
> done so.   It would seem a good idea in order to get the medicine in
> contact with the infection.  This of course leaves aside the question
> of a ruptured tm, i assume OE clinically.
>
> danka,
> don
> Donald Zweig MD
> [log in to unmask]
>
>
>
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