Version May 2024
INTRODUCTION — Tympanostomy tube otorrhea (TTO) may occur immediately after tube insertion from an existing infection in the middle ear (acute otitis media [AOM]) or later with subsequent middle ear infections or infectious processes in the ear canal.
The prevention and management of TTO in children are discussed here. An overview of TT placement and the postoperative care of children with TTs is provided separately. The indications for TT placement (eg, recurrent AOM, otitis media with effusion, and chronic suppurative otitis media) are also discussed separately:
●(See "Overview of tympanostomy tube placement, postoperative care, and complications in children".)
●(See "Acute otitis media in children: Clinical manifestations and diagnosis".)
●(See "Acute otitis media in children: Treatment".)
●(See "Acute otitis media in children: Prevention of recurrence".)
●(See "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis".)
●(See "Otitis media with effusion (serous otitis media) in children: Management".)
●(See "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis".)
TERMINOLOGY
Tympanostomy tube otorrhea — Tympanostomy tube otorrhea (TTO; also called post-tympanostomy tube otorrhea [PTTO]), is defined as active drainage through an existing TT [1]. TTO is primarily caused by a bacterial infection. TTO can be categorized according to its timing [2,3]:
●Early-onset TTO occurs within two weeks of tube placement
●Late-onset TTO occurs >2 weeks after tube placement
●Chronic or persistent TTO usually refers to otorrhea lasting for ≥6 to 8 weeks
●Recurrent TTO refers to distinct episodes of TTO between which the otorrhea clears
Chronic suppurative otitis media — Chronic suppurative otitis media (CSOM) is defined as purulent otorrhea that lasts for longer than six weeks despite treatment [1]. It may result from an unresolved or complicated acute otitis media (AOM) with perforation of the tympanic membrane or from a preexisting perforation. CSOM is discussed in detail separately. (See "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis" and "Chronic suppurative otitis media (CSOM): Treatment, complications, and prevention".)
PREVENTION OF TYMPANOSTOMY TUBE OTORRHEA
Early onset — Approximately 10 to 20 percent of children who undergo TT placement develop early-onset otorrhea due to bacterial infection, which increases the risk of tube occlusion [2,4]. Given the frequency of this complication, our practice is to routinely administer ear drops in the postoperative period to prevent early-onset TTO. However, there is a lack of consensus among otolaryngologists regarding whether prophylaxis against early-onset tube otorrhea is routinely warranted, which ear drops are most effective and least harmful, and what dosing regimen should be used [5]. Our suggested approach differs from the guidelines of the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF), which recommend against the routine use of topical antibiotics in the perioperative setting [6]. Alternative options for prevention of early TTO include intraoperative multiple saline washouts or an intraoperative single-dose application of topical antibiotic (with or without corticosteroid) [7-9]. While all of these interventions have been shown to reduce the risk of early TTO compared with no prophylaxis, few studies have directly compared the different approaches to one another. The beneficial effect of prophylaxis appears to be more pronounced among patients who have middle ear effusion at the time of TT insertion [7,10,11].
Our usual approach to perioperative prophylaxis is as follows:
●At the time of surgery – We typically use oxymetazoline nasal spray (five drops) intraoperatively, which also helps achieve hemostasis at the incision site.
Our preference for oxymetazoline (which is a commonly used topical nasal decongestant solution) at surgery is based on its low cost, its favorable safety profile, and observational data that suggest that it is equally effective in preventing early TTO compared with topical antibiotics (ie, ciprofloxacin) [12]. Systemic side effects are not seen with ototopic use of this medication at this dose, since little of the medication comes into contact with the mucous membrane. In addition, the medication does not appear to cause ototoxicity, based on a single animal study [13]. Though oxymetazoline causes stinging and discomfort in the ear when used in an awake patient, this is not a concern when it is used in the operating room.
●Postoperatively – We suggest topical fluoroquinolone drops (ofloxacin or ciprofloxacin) for postoperative prophylaxis [14]. The dose and duration of treatment depend on whether there is active infection at the time of surgery:
•In patients without evidence of active middle ear infection at the time of surgery (ie, dry ears or those with serous or mucoid middle ear effusions), we instruct the family to instill three drops into the ear twice daily for three days postoperatively.
•In patients with active middle ear infection at the time of surgery, we prescribe the antibiotic drops at treatment doses (eg, ofloxacin or ciprofloxacin, with or without steroid, four drops instilled into the ear twice daily for five to seven days).
If cost is a limitation, generic ciprofloxacin eye drops can be used as a low-cost alternative. Both the otic and ophthalmologic preparations of topical fluoroquinolone drops are stable at room temperature for at least four months, so parents can be instructed to keep the remaining solution to use at a later time should the child require subsequent treatment for TTO [15].
The use of topical antibiotics in this setting has been studied in randomized trials and meta-analyses, which reached variable conclusions [7,8,11,16]. A systematic review and meta-analysis identified 11 randomized and quasi-randomized trials of various topical antibiotics compared with no prophylaxis postoperatively in children undergoing TT placement [7]. Most of the trials had serious methodologic limitations (ie, lack of blinding, incomplete follow-up). In the three trials (n=928 children) that were deemed to be of high methodologic quality, postoperative administration of antibiotic drops reduced the incidence of otorrhea in all three trials (absolute reduction ranged from 7 to 34 percent). A subsequent randomized trial published after the meta-analysis did not detect a statistically significant reduction in the rate of early otorrhea in patients treated postoperatively with topical ciprofloxacin compared with normal saline (17 versus 24 percent, respectively) [16]. However, there was a high rate of loss to follow-up (36 percent), which may have limited the ability to detect a significant effect.
Alternative options for prevention of early-onset TTO that have demonstrated efficacy based on randomized clinical trials and meta-analyses include the following [7-9]:
•Intraoperative multiple saline washouts
•Intraoperative single-dose application of topical drops (antibiotic with or without a corticosteroid)
•Oral antibiotics
There are insufficient data, particularly head-to-head comparisons, to determine which ear drops (eg, saline, antibiotic alone, combination antibiotic/corticosteroid, oxymetazoline) are most efficacious for preventing early postsurgical otorrhea [10,12,17-20]. We prefer topical fluoroquinolone drops because of their favorable safety profile.
Potential toxicity is also an important consideration. One trial (involving aminoglycoside ear drops) included in the meta-analysis assessed ototoxicity and found no effect on hearing. Two subsequent randomized controlled trials of ciprofloxacin otic suspension also found no evidence of ototoxicity [8,9].
The only agent specifically approved by the US Food and Drug Administration for use at the time of TT insertion to prevent TTO is 6% ciprofloxacin gel [21]. An industry-sponsored phase 3 trial suggested efficacy compared with no treatment [9].
Late onset and recurrent — Approximately 30 percent of children who undergo placement of TTs have at least one episode of late-onset TTO while the tube remains in place (picture 1), and 7 percent develop recurrent TTO [2]. (See 'Acute tympanostomy tube otorrhea' below and 'Chronic tympanostomy tube otorrhea' below.)
Prevention of recurrent TTO in young children during the winter months (ie, cold and flu season) involves the same measures used to control recurrent acute otitis media (AOM) in infants and young children. (See 'Risk factors' below and "Acute otitis media in children: Prevention of recurrence".)
These measures include [22-24]:
●Handwashing (see "Infection prevention: Precautions for preventing transmission of infection", section on 'Hand hygiene')
●Immunization against Streptococcus pneumoniae and influenza (S. pneumoniae immunization is part of the universal immunization schedule for infants and young children in the United States; influenza vaccination is recommended for all children aged six months and older) (see "Seasonal influenza in children: Prevention with vaccines", section on 'Target groups' and "Pneumococcal vaccination in children", section on 'Routine immunization for children <5 years')
●Withdrawal from daycare, if feasible
The effect of prophylactic antibiotics in the prevention of TTO has not been studied [25].
Water precautions — The need for water precautions (eg, the use of ear plugs, swimming caps, or antibiotic-containing ear drops) in children with TTs is discussed separately. (See "Overview of tympanostomy tube placement, postoperative care, and complications in children", section on 'Water precautions'.)
ACUTE TYMPANOSTOMY TUBE OTORRHEA — Acute TTO in children refers to TTO that lasts less than six weeks. It usually results from acute otitis media (AOM) following an upper respiratory infection or from the introduction of contaminated water from the ear canal into the middle ear.
Pathogens — In children two years and younger, acute TTO is usually caused by the same pathogens that cause AOM in children without tubes (eg, S. pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae) [26-30]. Pseudomonas aeruginosa and Staphylococcus aureus are more prevalent in cases of TTO that persist despite oral antibiotic therapy and in older children in whom TTO is usually induced by water penetration [26,27,30,31]. Gram-negative organisms such as Pseudomonas and Eikenella are more common when granulation tissue is present [32]. One study found methicillin-resistant S. aureus (MRSA; in 6 percent of TTO) [33]. Most cases of TTO are polymicrobial, and viruses are isolated in approximately 20 percent [30]. (See "Acute otitis media in children: Epidemiology, microbiology, and complications", section on 'Microbiology'.)
Risk factors — The risk of early- and late-onset otorrhea depends upon patient and environmental factors:
●Early onset – The risk of early postoperative otorrhea is increased among children younger than two years of age and children with inflamed middle ear mucosa, mucoid effusion, and bacterial pathogens in the ear canal or middle ear effusion at the time of surgery [34,35]. However, the rate of early postoperative otorrhea is not affected by surgical technique or preparation of the ear canal [34,36].
●Late onset – Infants and young children with tubes inserted to control recurrent episodes of AOM are more likely to experience late-onset otorrhea than older children who have tubes inserted for otitis media with effusion (chronic otitis media) [35]. In temperate climates, TTO occurs most often during the winter months in young children and the summer months in older children, coinciding with upper respiratory infection season and swimming season, respectively [26].
Natural history — Untreated acute TTO resolves spontaneously in at least one-half of children within 14 days of onset [37]. Its long-term natural history is unknown. Similarly, viral myringitis (tympanic membrane erythema without purulent infection) and early AOM may resolve spontaneously without drainage because the tube provides middle ear ventilation.
Treatment — The treatment of acute TTO in children depends upon the age of the child, clinical status, and most likely pathogens. Uncomplicated cases are typically treated with topical antibiotic ear drops with or without corticosteroids, and oral or parenteral antibiotics are reserved for children with a concurrent infection (eg, sinusitis, streptococcal pharyngitis, adjacent auricular cellulitis) or blocked external auditory canal or those who are immunocompromised [6,38]. Patients are usually treated empirically, with culture of the middle ear fluid reserved for patients with refractory disease or ill-appearing infants with concomitant systemic infection. Aural toilet (ie, suctioning copious discharge, either by a primary care clinician using a short 8-French suction catheter or by an otolaryngologist using an operating microscope to guide a metal suction tube) aids in penetration of ototopic drops and may hasten resolution [1,39]. (See "Chronic suppurative otitis media (CSOM): Treatment, complications, and prevention", section on 'Aural toilet'.)
Uncomplicated acute tympanostomy tube otorrhea
Choice of therapy — For children with uncomplicated acute TTO (ie, without systemic symptoms, occlusion of the auditory canal, auricular cellulitis, or immunocompromise), we suggest topical therapy with ear drops containing a fluoroquinolone plus a corticosteroid (eg, ciprofloxacin and dexamethasone otic suspension, four drops into the affected ear twice daily for five to seven days). Observation is also an option for such patients since many of these episodes resolve spontaneously [2,40]. However, topical therapy should be given if the otorrhea does not resolve within one week. (See 'Natural history' above.)
Fluoroquinolone-containing drops (eg, ofloxacin, ciprofloxacin-dexamethasone, ciprofloxacin-fluocinolone acetonide) are preferred over aminoglycoside ear drops due to their broad antimicrobial spectrum, lower risk of ototoxicity, lower rate of contact dermatitis, and twice-daily dosing [3,18,41-44]. Compared with oral amoxicillin-clavulanate, topical fluoroquinolone has the advantage of providing activity against P. aeruginosa, a common pathogen in TTO, particularly in older children (see 'Pathogens' above). Fluoroquinolone-containing drops are the only topical antimicrobials approved by the US Food and Drug Administration for treating otorrhea with a nonintact tympanic membrane. Although fluoroquinolones are generally thought to be safe and less ototoxic (compared with aminoglycosides), retrospective studies suggest that they may increase the risk of persistent tympanic membrane perforation [45,46].
Addition of a corticosteroid to the antibiotic preparation enhances cure when granulation tissue is present (picture 2) [41,47]. In addition, the topical corticosteroid may modestly improve the efficacy of the antibiotic [48]. The available steroid-containing ototopical preparations are fairly costly, and some insurers may not cover them. If cost is an issue, generic ciprofloxacin 0.3% eye drops can be used in the ear with similar effect as the ototopical preparations [49].
If the child fails to respond with resolution of visible otorrhea after seven days of topical therapy, a trial of oral antimicrobial therapy or referral to a pediatric otolaryngologist for cleaning of the tube orifice and culture of the middle ear fluid may be warranted. (See 'Complicated acute tympanostomy tube otorrhea' below and 'Chronic tympanostomy tube otorrhea' below.)
The efficacy and safety of combined topical fluoroquinolone plus corticosteroid therapy for acute TTO is supported by several randomized trials [37,48,50-53]. In one trial comparing topical ciprofloxacin/dexamethasone with oral amoxicillin/clavulanate, topical therapy resulted in shorter duration of otorrhea (four versus seven days) and higher rate of clinical cure (85 versus 59 percent) [50]. Similar findings were noted in a trial comparing topical ofloxacin with oral amoxicillin/clavulanate [51]. In both trials, topical therapy was better tolerated than oral antibiotic therapy. In another randomized trial, treatment with combined topical ciprofloxacin plus corticosteroid (fluocinolone) resulted in a higher rate of clinical cure at three weeks compared with either agent alone (81 versus 67 and 48 percent, respectively) [53].
Administration of ear drops — Antibiotic ear drops work well when instilled into a thoroughly cleaned ear with a patent TT. It is less clear whether they work when applied over a collection of pus from a rapidly discharging AOM [54,55]. In an observational study using an in vitro model, ear drops instilled into a clean external ear canal did not consistently pass through the TT. Entry into the middle ear was facilitated by application of slight tragal pressure [55].
Ideally, the ear canal should be cleaned by the clinician with suction or repeated cotton swabbing before instilling drops. Having the child lie down with the affected ear up for a few moments promotes penetration. The optimal number of drops has not been established. According to the package inserts, the dose for ofloxacin is five drops and the dose for ciprofloxacin-dexamethasone is four drops. (See "Chronic suppurative otitis media (CSOM): Treatment, complications, and prevention", section on 'Aural toilet'.)
Complicated acute tympanostomy tube otorrhea — Complicated acute TTO refers to acute TTO in the setting of any of the following:
●Ill appearance, signs of systemic infection, or severe symptoms (eg, high fever, lethargy, severe ear pain)
●Auricular cellulitis
●Occlusion of the auditory canal
●Immunocompromise
For patients with complicated acute TTO, we suggest systemic (oral or parenteral) antibiotics for ill-appearing infants and older children with acute TTO and systemic infection or severe symptoms (eg, fever, lethargy, severe ear pain, copious otorrhea, associated upper respiratory symptoms) [1,44]. Antibiotic therapy should have activity against common AOM pathogens (eg, S. pneumoniae, M. catarrhalis, H. influenzae). We suggest high-dose amoxicillin (75 to 100 mg/kg/day divided twice daily for 10 days) or amoxicillin-clavulanate (with high-dose amoxicillin) as empiric therapy. (See "Acute otitis media in children: Treatment", section on 'Initial antibiotic therapy'.)
There are few high-quality studies assessing the efficacy of systemic antibiotic therapy for acute TTO in children [39,56]. In one small randomized trial, oral amoxicillin-clavulanate was compared with placebo in 79 children with acute TTO of <48 hours duration [56]. All patients underwent daily suctioning of middle ear fluid through the TT. Treatment with amoxicillin-clavulanate resulted in shorter duration of otorrhea (three versus eight days) and higher rate of resolution of otorrhea (82 versus 41 percent). However, the generalizability of these findings may be limited since it is not routine practice to perform daily suctioning in children treated with oral antibiotics [39].
●Ill appearance and systemic symptoms – Ill-appearing infants may have concomitant systemic infection (eg, pneumonia, bacteremia) for which topical therapy has no effect. Bacterial culture of the discharge at the initiation of therapy may be useful in these children. Culture data can help guide antimicrobial therapy should empiric treatment fail. (See "Approach to the ill-appearing infant (younger than 90 days of age)", section on 'Empiric therapy'.)
●Associated cellulitis – We suggest that children with acute TTO complicated by auricular cellulitis be treated with a combination of systemic and topical therapy. If possible, culture of the drainage should be obtained before antibiotic therapy is initiated. Empiric therapy should include oral antibiotics with activity against S. aureus and S. pneumoniae (eg, amoxicillin-clavulanate) in addition to topical antibiotics. Placing a porous wick in the inflamed ear canal may facilitate entry of the ototopic drop if the canal is occluded by secondary otitis externa [57,58]. (See 'Pathogens' above and "External otitis: Pathogenesis, clinical features, and diagnosis".)
●Occluded auditory canal – The ability of topical therapy to reach the middle ear may be compromised in children with TTO complicated by occlusion of the auditory canal [3]. Occlusion may be caused by cerumen impaction or a foreign body. Empiric antimicrobial therapy in such cases should be based upon the most likely pathogens in the particular age group of the child. In addition, removal of the foreign body or obstructing cerumen may result in decreased otorrhea and improved access to the middle ear through the TT. (See 'Pathogens' above and "Acute otitis media in children: Treatment", section on 'Initial antibiotic therapy'.)
If the child fails to respond with resolution of visible otorrhea within five days, we suggest the addition of an antibiotic ear drop with activity against P. aeruginosa and S. aureus (eg, a fluoroquinolone). If possible, the ear canal should be cleaned with an 8-French suction catheter and the discharge sent for culture and sensitivities before the ear drops are prescribed. (See 'Uncomplicated acute tympanostomy tube otorrhea' above.)
If otorrhea persists three to five days after the addition of topical therapy, referral to a pediatric otolaryngologist is warranted for a thorough cleaning of the tube orifice and culture of the middle ear fluid. Management of persistent otorrhea is discussed below. (See 'Chronic tympanostomy tube otorrhea' below.)
CHRONIC TYMPANOSTOMY TUBE OTORRHEA — Chronic TTO refers to otorrhea that persists for six weeks with or without initial treatment with an ototopical antimicrobial and/or oral antibiotics. It develops in approximately 4 percent of patients after placement of TTs [2].
Causes — A common cause of refractory TTO in children treated with topical agents is persistent bacterial infection due to inadequate penetration of the drops because of inspissated or accumulated debris in the ear canal. Most such cases resolve promptly after thorough cleaning, suctioning of the TT, and application of a topical corticosteroid-antibiotic drop for five to seven days.
Prolonged use of any topical antimicrobial, particularly broad-spectrum fluoroquinolones, may result in fungal overgrowth [59,60]. Children with fungal overgrowth present with thick fungal debris and clogged, itchy, or painful ears (picture 3).
Community-acquired methicillin-resistant S. aureus (CA-MRSA) and multiple drug-resistant S. pneumoniae are other potential causes of TTO refractory to the usual antimicrobial therapy described above [61,62]. (See "Methicillin-resistant Staphylococcus aureus infections in children: Epidemiology and clinical spectrum", section on 'CA-MRSA strains'.)
Otorrhea persisting despite aural toilet (ie, suctioning of discharge from the ear canal), dry ear precautions, and intensive medical management may be caused by granulation tissue (picture 2), an occult cholesteatoma, or unusual pathogens, such as Candida albicans, Actinomyces, or Aspergillus [59,60,63,64]. Referral to an otolaryngologist is warranted in such patients to prevent the development of serious sequelae. (See "Cholesteatoma in children".)
Other potential causes of chronic or recurrent TTO include immunodeficiency (particularly when associated with other upper and lower respiratory tract infections) and chronic adenoiditis [1]. (See "Approach to the child with recurrent infections".)
Management — Children with chronic TTO should be referred to their otolaryngologist. It is desirable to directly suction the tube orifice under magnification to obtain middle ear discharge for culture and to ensure adequate cleaning [65]. If this is impossible because of equipment limitations or an apprehensive child, drying the ear canal with multiple cotton applicators or suctioning with a short flexible 8-French catheter are alternative ways to clear debris and permit entry of ear drops [66].
We recommend obtaining bacterial culture and sensitivities of the purulent drainage in the ear canal in cases of refractory otorrhea. A fungal stain/culture should also be ordered if the laboratory does not report common fungi on routine culture. Culture is particularly important for detection of resistant organisms (eg, CA-MRSA) or fungal overgrowth after prolonged antibiotic therapy. (See "Staphylococcus aureus in children: Overview of treatment of invasive infections", section on 'MRSA infections'.)
We recommend that antimicrobial therapy for refractory otorrhea be based upon culture and susceptibility results. In one case series, fungal TTO was successfully treated with thorough cleaning under binocular microscopy and application of topical clotrimazole solution [60]. Some patients required multiple treatments and/or systemic antifungal therapy (oral fluconazole for seven days).
Successful eradication of refractory TTO caused by CA-MRSA has been reported with three regimens: oral trimethoprim-sulfamethoxazole with topical gentamicin or Cortisporin otic drops [61], vancomycin otic drops (not available in the United States) [62], and mupirocin [67,68]. Mupirocin was not ototoxic in an animal model, but vancomycin was [69]. Several children who had CA-MRSA otorrhea were successfully treated with oral linezolid [70]. Linezolid is available as a palatable oral suspension, but it is expensive. Parenteral antimicrobial therapy is warranted in some cases [71]. (See "Staphylococcus aureus in children: Overview of treatment of invasive infections", section on 'MRSA infections'.)
Removing a TT is occasionally necessary to stop refractory otorrhea [2,71,72]. Bacterial biofilms can form on mucosal surfaces and implanted prostheses, including TTs (picture 4) [73]. These bacterial aggregates are resistant to therapy with systemic antibiotics and are not detected with standard culture methods. (See "Overview of tympanostomy tube placement, postoperative care, and complications in children", section on 'Tube removal'.)
Evaluation for possible immunodeficiency may be warranted in children with TTO caused by unusual pathogens, refractory chronic TTO, or frequent TTO in association with other upper and lower respiratory tract infections. (See "Approach to the child with recurrent infections".)
PROGNOSIS — For most patients, TTO is brief, painless, and not recurrent [26]. Chronic TTO develops in approximately 4 percent of patients after placement of TTs, and recurrent TTO develops in 7 percent [2].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Acute otitis media, otitis media with effusion, and external otitis".)
SUMMARY AND RECOMMENDATIONS
●Tympanostomy tube otorrhea (TTO) is defined as active drainage through an existing TT. Early-onset TTO occurs within two weeks of tube placement. Late-onset TTO occurs more than two weeks after tube placement. (See 'Terminology' above.)
●For all children who undergo TT placement, we suggest administering topical fluoroquinolone ear drops (eg, ofloxacin or ciprofloxacin drops, with or without corticosteroid) postoperatively to prevent early-onset TTO (Grade 2C). Alternative options for prevention of early TTO include intraoperative multiple saline washouts and an intraoperative single-dose application of topical antibiotic or antibiotic/corticosteroid drops. The dose and duration of postoperative topical antibiotic therapy depend upon whether there is evidence of active middle ear infection at the time of surgery. In patients without evidence of active infection, the regimen consists of five drops into the ear twice daily for three days postoperatively. If there is active middle ear infection at the time of surgery, the regimen consists of four drops into the ear twice daily for five to seven days. (See 'Early onset' above.)
●Prevention of recurrent TTO in infants and young children involves the same measures used to control recurrent acute otitis media (AOM), including immunization, handwashing, and withdrawal from daycare, if feasible. (See "Acute otitis media in children: Prevention of recurrence" and "Seasonal influenza in children: Prevention with vaccines", section on 'Target groups' and "Pneumococcal vaccination in children", section on 'Routine immunization for children <5 years'.)
●Water precautions are not generally recommended, although they are advised in certain situations (eg, swimming in a lake, pond, river, or ocean; submerging in a bath; deep diving) and for certain patients (eg, those with active, recurrent, or prolonged otorrhea; those with a prior history of problems with water exposure). (See "Overview of tympanostomy tube placement, postoperative care, and complications in children", section on 'Water precautions'.)
●In children two years and younger, TTO is usually caused by Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenza. In cases of persistent TTO and in older children in whom TTO is usually induced by water penetration, Pseudomonas aeruginosa and Staphylococcus aureus are more prevalent. (See 'Acute tympanostomy tube otorrhea' above.)
●Treatment of acute TTO depends upon whether the infection is uncomplicated or complicated (ie, associated with systemic symptoms, auricular cellulitis, occlusion of the auditory canal, or immunocompromise) (see 'Treatment' above):
•For children with uncomplicated acute TTO, we suggest topical therapy with ear drops containing a fluoroquinolone plus a corticosteroid rather than topical aminoglycoside ear drops, oral antibiotics, or observation alone (Grade 2B). A typical treatment regimen consists of ciprofloxacin/dexamethasone drops: four drops into the affected ear twice daily for five to seven days. If cost is an issue, ciprofloxacin 0.3% eye drops can be used in the ear with similar effect. Observation is a reasonable alternative for selected patients since some of these episodes resolve spontaneously. (See 'Uncomplicated acute tympanostomy tube otorrhea' above.)
•For children with complicated acute TTO, we suggest systemic rather than topical antimicrobial therapy (Grade 2C). Empiric therapy typically consists of high-dose amoxicillin (75 to 100 mg/kg/day divided twice daily for 10 days) or amoxicillin-clavulanate (with high-dose amoxicillin). (See 'Complicated acute tympanostomy tube otorrhea' above.)
●Children with refractory TTO should be referred to their otolaryngologist for further evaluation and treatment. Antimicrobial therapy for refractory otorrhea should be based upon culture and sensitivity results. (See 'Chronic tympanostomy tube otorrhea' above.)
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