Emergency Medicine Forum

An 11 y/o female presents with her mom complaining of ear pain.  She is on the summer swim team and frequently gets ear infections.   This one is particularly bad as the pain is quite severe.  Mom also describes  a ’boil’ on her buttock, and shares with you that she has no insurance and is worried about the expense of the ED visit.
 
PE:  Normal Vital signs, and exam remarkable only for:

Obesity:  Weight approximately 170 lbs, height 4’10”inches.  (BMI=35.5)

There is pain on traction of the right pinna.  The right ear has significant swelling to the external canal.  TM is not visualized because of the significant swelling. Some lymph nodes are palpable.  Otherwise, HEENT is unremarkable.

Back: Small 1 inch fluctuant abscess with surrounding 1 inch of erythema on buttock cheek.  Tender to touch, consistent with small abscess with surrounding cellulitis.

Questions:

1.  How can you be sure the antibiotic drops for the otitis media will get into the ear with all of the swelling in the canal?  If you decide to use cortisporin otic drops, should you use the suspension or the solution? Are there any adverse side effects from using cortisporin?  What can mom do to prevent any future otitis externa?

When the ear canal is substantially closed due to edema, you can treat orally, or you can place a wick.  An ear wick is a small piece of expandable sponge that expands when it gets wet. They are available commercially.  It hurts to place them, but only for a second.  To see pictures of what they look like, click on either of the two links at the end of this answer.  After placing the ear wick, moisten it with the ear drops, and it will expand. (1) When using cortisporin ear drops, you should NOT use the solution if there is any defect in the tympanic membrane (i.e. you can’t see the TM), because of the possibility of neomycin toxicity. (2) For that reason, I only use the suspension. A recent comparison of Ciprofloxin otic drops to Cortisporin found that Cipro was superior.  (3)  An earlier study found treatment with Ciprodex (cipro plus dexamethhasone) was microbiologically superior to cortisporin. (4). However it is more expensive, so in patients without insurance, I discuss these options and involve them in the decision.  Some without insurance would rather have the more expensive medication, and are willing to pay for it.  Others are willing to accept the 8% less cure rate using the cheaper, more traditional medications.
 
Another option when the canal is severely swollen is to prescribe oral antibiotics.  The most common organisms are pseudomonas Aeruginosa and Staph Aureus, or other gram negative organisms.
 
Keeping the ear dry will help prevent future infections.  Simply using ear plugs when she swims is quick and easy.  Other methods to keep the ear dry is to put a mixture of 50% rubbing alcohol, 25% white vinegar, and 25% distilled water together in a small bottle, then place a few drops in each ear twice a day.  (1) The alcohol helps to dry the ear, the mild acidic nature of the vinegar helps keep the bacteria count down.  You should not do this if there is any chance of a perforation.

http://images.google.com/imgres?imgurl=http://www.doylemedical.com/images/Original%2520Wick%2520Illustration.JPG&imgrefurl=http://www.doylemedical.com/totowick%2520illustration.htm&usg=__V4drjE0TskhSifZzJ9pV5kxmxcs=&h=474&w=665&sz=68&hl=en&start=2&tbnid=nRa8VZCNa6XbaM:&tbnh=98&tbnw=138&prev=/images%3Fq%3Dear%2Bwick%26hl%3Den
 
http://www.fabco.net/catalog/earwicks.htm

2. If you decide to treat the cellulitis with antibiotics, where can you suggest this patient go for free antibiotics?  What drug stores offer discounted medications?

Many drug stores offer free or discounted medications.

 1. Meijer offers several common antibiotics for free (Anoxicillin, Cephalexin, SMZ-TMP, Ciprofloxin,     Ampicillin, PCN VK, and Erythromycin).  For more information see Ref #5.  Meijer also offers FREE prenatal vitamins.
 2. Wal-Mart offers numerous prescriptions (not just antibiotics) for only $4. And, additionally, there are several over the counter medications now offered for only $4 (see Ref #6 for lists of prescription and OTC $4 medications). 
 3. K-Mart offers numerous prescriptions for only $5.  (See Ref #7 for entire list)
 4. Target also offers $4 medications.  (For list see Ref #8)

3. Do you need to pack the abscess after you drain it?

Traditionally, we usually incise and drain an abscess (I and D), then pack it to keep the abscess cavity open.  However, a small study from Australia suggests that if the abscess is less than 5cm in diameter, you may not need to pack it. (9)  In this study, they included abscess’s that needed to be drained under general anesthesia, so it may not be completely applicable to the ED. 
As I’m still a little old fashioned, I still pack them.

4. Is there anything else besides the medications for the ear and draining the abscess you can do for this child?

I would consider a few additional things: 
 1. First, as she is obese, and without insurance, I often will do a quick accucheck. It’s cheap, and it can help   eliminate the potential for untreated Type II Diabetes.
 2. Next, I will often have a quick discussion with children who are obese regarding their diet.  Many drink   themselves into obesity with juice and pop.  Getting them to switch to healthier substitutions can make a   huge difference. I also discuss physical activity (but at least this girl is in swim class), and limiting   watching TV/computers (doing no physical activity except eat for hours).  In this case, as I’m draining the   abscess I can explain all of this, so often it doesn’t take extra time.
 3. Finally, in most states, subsidized children’s health insurance is available.  I provided mom with     information on MIChild (Children’s Health Insurance Program in Michigan) See Ref #10 for more information.

Outcome:
Accucheck was normal, the ear didn’t require a wick (although I couldn’t see the entire TM, the swelling was not occlusive).  After discussion with mom, she wanted the cortisporin otic drops.  I drained and packed the small abscess.  I also gave her 2 Tylenol #3 in the department.  I directed her to Meijer for free TMP-SMZ (Trimethoprim / Sulfamethoxazole) for the cellulitis around her buttock abscess.  (Many would argue that just draining it was enough, but she also had a cellulitis, so I elected to treat).  I also discharged her with a few Tylenol #3 for the next few days if Ibuprofen was not holding the pain. She was instructed to return to the ED or follow up in the pediatric clinic for packing removal.

It turned out she drank about 5 Coke’s a day.  She agreed to switch to water.  Finally, I discharged her with the information to apply for MIChild, which was probably the most important thing I did for her.

References:
1. Waitzman AA. Otitis Externa.  Emedicine.  Mar 14, 2008.  Accessed at: http://emedicine.medscape.com/article/994550-overview
2. Glaxo Wellcome, Cortisporin.  Accessed at: http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20(General%20Monographs-%20C)/CORTISPORIN.html
3. Drehobl M, Guerrero LJ, Lacarte PR, Goldstein G, Mata FS, Luber S.  Comparison of efficacy and safety of ciprofloxacin otic solution 0.2% versus polymyxin B-neomycin-hydrocortisone in the treatment of acute diffuse otitis externa.  Cur Med Res Opinion 2008 Dec; 24(12):3531-42.  Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/19032135?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
4. Roland PS, Pien FD, Schultz CC, et al.  Efficacy and safety of topical ciprofloxacin/dexamethasone versus neomycin/polymyxin B/Hydrocortisone for otitis media.  Curr Med Res Opin 2004 Aug; 20(8):1175-83. Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/15324520?ordinalpos=19&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
5. Meijer free antibiotic list: https://www.meijer.com/pharmacy  then click on free antibiotics.
6. Wal-Mart discounted medications: Prescription $4 medications: http://i.walmartimages.com/i/if/hmp/fusion/customer_list.pdf  and OTC $4 lists:   http://i.walmart.com/i/if/hmp/fusion/OTC_drug_List.pdf
7. K-Mart Discounted medications for $5: http://www.kmart.com/ue/home/kmrx.5_Prescriptions.pdf
8. Target Discounted medications for $4 http://www.rxassist.org/providers/documents/TargetGenericsProgramDrugList.pdf
9. Abraham N, Doudle M, Carson P. Open versus closed surgical treatment of abscesses:  a controlled clinical trial.  Aust N Z J Surg 1997 Apr; 67(4):173-6.  Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/9137156?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
10. MICHILD  Michigan Subsidized health insurance program in Michigan: http://www.michigan.gov/documents/MIChild_english_5_65774_7.03_pms539.pdf   AND http://www.michigan.gov/mdch/1,1607,7-132-2943_4845_4931—,00.html