Stuart had started with a cold on Friday but was fine in himself. On Saturday, he seemed a bit under the weather. He now had a sore throat and a cough. He didn’t want to go to play in the park: his mum was supposed to be taking him to meet his friend, Peter, there. They would be up and down the slide and racing around every Saturday morning.

Stuart laid on the sofa and watched television for most of the day. He didn’t seem too bad on Sunday and went to school, as usual, on Monday.

Stuart said that he still had a sore throat when he got back from school. He felt tired after his tea and went to bed early. He woke up in the middle of the night. He was crying with a bad earache. It settled down with paracetamol. When Stuart got up that morning, his ear was hurting again and he looked hot. He didn’t want breakfast. He did eat two biscuits and, about an hour later, was sick. He spent the rest of the day in bed. He slept quite a lot and, every time he woke up, his ear hurt. His Mum thought that he had had a temperature for most of the day.

On Wednesday, when she went to wake him up, Stuart’s mum noticed yellow pus in his right ear. There was a streak of blood in it. She was surprised to see that, in himself, he looked better. He grinned. He said that his ear was no longer hurting. He wanted some breakfast and ate it all.

When I saw Stuart that afternoon, he was still feeling well. His temperature was normal. His throat was red, but his tonsils were not enlarged. His right ear canal (external auditory meatus) was full of pus. The canal walls did not seem inflamed or swollen. I was unable to see the ear drum because of the pus.

It seemed likely that Stuart had a middle ear infection (otitis media) with a perforated ear drum. I prescribed a course of antibiotics.

Although this is a fairly straightforward case, I want to discuss the three different stages of the illness. It can be helpful from a diagnostic point of view to look at how an illness progresses and how symptoms change over time.

I often forgot to ask patients if there symptoms were getting better or worse.

The first stage of this illness was a cold with a runny nose, sore throat and cough that lasted for four days. It sounds as if Stuart might have had a bit of a temperature on the Saturday. Apart from this, he seemed well. If there had been no complications, we might have expected Stuart to have fully recovered within a week of his symptoms starting.

Colds are caused by viral infections. They sometimes cause a temperature. This most often begins on the first or second day. Viral infections are normally eliminated by our immune systems within a week or two.

On the Monday night, Stuart’s illness changed. He developed an earache, a fever and felt generally unwell. This suggested that a ‘complication’ had developed in addition to the cold.

The commonest complications of colds in children are ear or chest infections. Adults are more likely to develop sinus or chest infections. We call these infective complications, secondary infections. They are usually bacterial.

We are not sure why secondary infections occur. They may be due to a combination of factors. It is thought that, when our immune system is preoccupied with a virus, it may not be able to tackle bacteria as effectively as normal.

In the case of a secondary ear infection, the cold causes inflammation, swelling and congestion of the eustachian tube:  this is the thin tube that drains the middle ear. Blockage of the eustachian tube allows bacteria to build up in the middle ear, leading to the infection.

The middle ear is an enclosed space. As bacteria multiply, the pressure in the middle ear cavity builds up and causes severe pain.

Stuart’s ear infection might have continued for several days. Ear infections often resolve without treatment. Some patients require antibiotics.

In the third stage of Stuart’s illness, the pressure inside his middle ear increased causing his ear drum to burst. Perforation of the ear drum allowed the bacteria to escape and relieved the pressure. This reduced Stuart’s pain and made him feel a lot better.

Fortunately, the majority of ear drums that perforate as a result of infection heal up completely, restoring hearing to normal.

In Stuart’s case, a detailed history gives us a clear idea of what is likely to have happened. This is confirmed by our examination findings.

The same sort of pattern could occur with a secondary chest infection. The patient starts with a cold, and then, develops a fever, a change in their cough and becomes more breathless.

The diagnosis of a secondary infection may not be quite as obvious with an initial illness that causes a fever such as influenza. The early development of a secondary infection, within the first twenty-four or forty-eight hours, can also muddy the waters.

CAUSES OF AN EAR DISCHARGE IN CHILDREN

One of the commonest reasons for an ear discharge in children is a middle ear infection (otitis media) with a perforated ear drum. This can sometimes result in a chronic discharge. Inflammation of the external ear canal (otitis externa) is another important cause.

Otitis externa tends to cause itching, soreness, pain and a discharge which might be watery or contain pus. The discharge is not always present. The walls of the external auditory canal are red and swollen making the canal itself narrower. If the eardrum can be seen, it is intact.

Small children have a habit of sticking things into their ears. An injury or a foreign body can also cause a discharge. An injury may cause bleeding.

A child with a recurrent or persistent ear discharge needs to have a careful specialist assessment to ensure that he does not have a more serious cause such as a cholesteatoma.