Ear and hearing problems ⚠️

• Ear infections can become chronic causing hearing impairment and long-term learning and social problems
• Important to treat ear problems AND manage disability related to hearing loss
• Serious ear problems are often asymptomatic (painless) — examine EVERY ear of EVERY child at EVERY opportunity

Ask

• How long has problem been going on
• Pain or tenderness — in ear, when moving outer ear, behind ear
• Discharge
• If more than 2 weeks — chronic suppurative otitis media (CSOM)
• If less than 2 weeks — acute otitis media with perforation (AOMwiP)
• Any swelling behind ear
• Any itch in ear
• Any problems with hearing or talking

Assessment

Check

See Ear examination

• Look in notes and ask about previous ear problems
• If intact ear drum and not too painful — test eardrum movement using pneumatic otoscopy or tympanometry
  

Otoscopy examination

Need clear view of eardrum for otoscopy examination. Do not syringe if any pain or any holes in ear drum

• Discharge — colour, type and amount. If any discharge — usually means perforation
• Blocked ear canal
• Pus — clean with tissue spears or syringe 
• Wax — soften by filling canal with docusate sodium ear drops for 2 nights before syringing only if ear drum intact
• Foreign body — syringe only if ear drum intact
• Eardrum — colour, bulge, perforation — Figure 7.21
• Hole in eardrum — note and record in file notes — Figure 7.22
• Size — small/pinhole (less than 2%), medium (2%–30%), large (greater than 30%), subtotal (very little ear drum remaining)
• Location — draw the size and position and note right or left ear

Ear examination charts

Photos provided by Dr Michael Hawke, Hawke Library.

Diagnosing ear problems

Treatment — general principles

• Pain relief
  
• If using ear drops — clean ears then tragal pump (gently push on ear flap) to help ear drops reach middle ear
• Teach parents how to safely clean ears and add drops
• Persistent otitis media or any CSOM — refer for both audiology (hearing test) and to ENT
• If tympanostomy tube otorrhoea or grommets with pus for 4 weeks or intermittent for 3 months — refer to treating ENT
• To reduce risk of long term disability due to poor hearing — give information to family and school (with consent) about hearing ability and provide strategies to improve hearing
• Reduce background noise, use clear louder speech, watch face of speaker, give lots of opportunities to learn speech and language
• Arrange classroom or individual amplification, sit at front with less distraction
• Refer to audiologist and speech pathologist

Acute otitis media without perforation (AOMwoP)

• Bulging ear drum with no perforation. May not be painful
• Audiometry is not recommended for episodic AOMwoP, however children at high risk with more than one episode should be referred for audiology

• If child under 2 years — may need many weeks of antibiotics or increased dose to get better and to prevent perforation

Do

• See Treatment — general principles AND
• Talk with family about importance of antibiotics to prevent chronic ear problems
• Give azithromycin oral — 30mg/kg — doses — single dose
• OR amoxicillin oral — adult 1g, child 25mg/kg/dose up to 1g — doses — twice a day (bd) for 7 days
• OR If they have been on antibiotics in past 30 days — give high dose  amoxicillin oral — adult 2g, child 50mg/kg/dose up to 2g — doses — twice a day (bd) for 7 days
• If allergy to penicillin — give trimethoprim-sulfamethoxazole oral — adult 160+800mg, child 4+20mg/kg/dose up to 160+800mg — doses — twice a day (bd) for 5 days

Review after 7 days

• If resolved – review in 4 weeks
• If on azithromycin and not resolved
• Give second dose of azithromycin oral — 30mg/kg — doses — single dose
• If on amoxicillin and not resolved
• Check compliance and if treatment regime is understood
• Give azithromycin oral — 30mg/kg — doses — single dose
• OR Increase to high dose amoxicillin oral — adult 2g, child 50mg/kg/dose up to 2g — doses — twice a day (bd) for 7 days
• If allergy to penicillin — medical consult

Review again after 7 days

• If resolved – review in 4 weeks
• If azithromycin started at last visit and not resolved
  
• Give second dose of azithromycin oral — 30mg/kg — doses — single dose
• If not resolved after 7 days of high-dose amoxicillin or two doses of azithromycin
• Give amoxicillin–clavulanic acid oral — adult 1,750+250mg, child 45+6.25mg/kg up 1,750+250mg — doses — twice a day (bd) for 7 days
• If allergy to penicillin — medical consult

Review again after another 7 days

• If resolved — review in 4 weeks
• If not resolved — medical consult

Acute otitis media with perforation (AOMwiP)

• Discharging ear for less than 2 weeks

Do

• See Treatment — general principles AND
• Give azithromycin oral — 30mg/kg — doses — single dose
• OR give high-dose amoxicillin oral — adult 2g, child 50mg/kg/dose up to 2g — doses — twice a day (bd) for 14 days
• If allergy — medical consult
• ALSO If discharge (pus) present clean ears THEN give ciprofloxacin — 5 drops, twice a day (bd) for 7 days
  

Review after 7 days

• If resolved — complete antibiotic course and review in 4 weeks
• If on azithromycin and ongoing discharge (pus) or perforation
• Give second dose of azithromycin oral — 30mg/kg — doses — single dose
• If on high dose amoxicillin and ongoing discharge (pus) or perforation
• Give azithromycin oral — 30mg/kg — doses — single dose
• OR amoxicillin–clavulanic acid oral — adult 1,750+250mg, child 45+6.25mg/kg up to 1,750+250mg — doses — twice a day (bd) for 7 days
• If allergy to penicillin — medical consult
• ALSO clean ears THEN give ciprofloxacin — 5 drops, twice a day (bd) for 7 days

Review after a further 7 days

• If not resolved within 2 weeks — treat as CSOM
• If resolved — routine monitoring

Recurrent AOM (rAOM)

• 3 episodes of AOM (with or without perforation) in last 6 months or 4 episodes in last 12 months

Do

• See Treatment — general principles AND
• Medical consult
• Refer for audiometry (hearing test)
• If hearing loss of more than 30dB and no imminent ENT surgery — refer for hearing aid consult
• Monitor and ask carers about delay in language development and increasing difficulties talking or hearing
• If under 2 years and at high risk of AOMwiP or CSOM — consider preventative antibiotics
• Give amoxicillin oral — adult 1g, child 25mg/kg/dose up to 1g — doses — twice a day (bd) for 3 months, then review
• If allergy — medical consult
• Tell parents/carers that preventative antibiotics should reduce number of infections by about half
• If doesn't improve — continue antibiotics and refer to ENT and paediatrician
• If rAOM fails to improve despite a trial of preventative antibiotics — refer to ENT for consideration of tympanostomy tubes, with or without adenoidectomy 

Chronic suppurative otitis media (CSOM)

• Perforation with discharge (pus) for 2 weeks or more and/or if tympanic membrane perforation can be visualised and size estimated to be adequate to allow topical treatments to pass through easily
• An easily visible perforation is more than 2%
• If you can’t see a perforation on the drum — do not use drops

Do

• See Treatment — general principles AND
• Clean until ear drum visible using tissue spears
  
• If pus thick — syringe first until you can see the eardrum
• After cleaning ears give ciprofloxacin — 5 drops, twice a day (bd) for 7 days
• If pinhole perforation — do not use ciprofloxacin drops initially — give amoxicillin oral — adult 2g, child 50mg/kg/dose up to 2g — doses — twice a day (bd) for 14 days or until perforation is dry for a week
• If allergy — medical consult
• Teach parents to clean/dry mop ears with tissue spears and put in drops
• Advise to keep ear as dry as possible

Persistent CSOM (after 4 months of treatment)

• If no visible perforation — stop drops — give trimethoprim-sulfamethoxazole oral — adult 160+800mg, child 4+20mg/kg/dose up to 160+800mg — doses — twice a day (bd) for 6-12 weeks 
• If allergy — medical consult
• Medical consult to consider hospital admission for IV or IM treatment
• Review weekly until CSOM resolved — no pus for more than 3 days
• If ear dry (no pus) but still perforation at end of treatment — treat as dry perforation and refer for hearing test
• Talk with parents about stimulating speech and language in a young child — lots of talking, going to preschool, childcare, early learning program

Dry perforation (hole)

Do

• Advise family to bring child back to clinic straight away if pus (discharge) from ear — treat as AOMwiP
• See Treatment — general principles AND
• If hole in eardrum for more than 3 months — hearing test and medical follow-up
• If child over 6 years with perforation not healed in 6–12 months OR hearing loss more than 30dB OR large perforation of any duration — refer to ENT. May need surgical repair
• If hearing impairment — make sure hearing support aids are used at home and school

Otitis media with effusion (OME) — glue ear

• Can be hard to diagnose
  
• No eardrum bulge
• Immobile eardrum or Type B tympanogram AND either fluid behind intact eardrum OR dull opaque intact eardrum
• Generally pain-free
• Symptoms may include talking, hearing or listening problems, behaviour problems or poor balance

Do

• See Treatment — general principles AND

 If problem for less than 3 months

• No investigation or treatment needed
• Reassure carers and suggest communication strategies
• Medical follow-up monthly. If persistent for 3 months — treat as for persistent OME
• If any hearing, speech, language concerns — refer to audiology
  

If persistent OME (OME in both ears for 3 months or more) 

• Medical consult
• Consider long-term antibiotics especially in young child at high risk of CSOM
• Give amoxicillin oral — adult 1g, child 25mg/kg/dose up to 1g — doses — twice a day (bd) for 2–4 weeks THEN review
• If allergy to penicillin — medical consult
• Refer for hearing test and ENT review — hearing aid if hearing loss more than 30dB in the better ear
• Talk with parents about stimulating speech and language in young child — lots of talking, going to preschool, childcare, early learning program
• If concerns about hearing, speech or language development at any time — refer to paediatrician, speech pathologist, audiologist

Otitis externa

• Ear canal sore, swollen, itchy
• Pain on moving outer ear

Do

• See Treatment — general principles AND
• Check for hole in eardrum — could really be middle ear disease
• Give dexamethasone-framycetin-gramicidin ear drops — put in drops​ by tilting head and filling ear canal
• OR triamcinolone-neomycin-gramicidin-nystatin ointment
• If ear canal very swollen, severe symptoms or poorly controlled pain — medical consult
• Keep ears dry (no swimming or wetting) for 2 weeks after finishing treatment

Infected grommets or Tympanostomy Tube Otorrhoea (TTO)

Do

• See Treatment — general principles AND

Complicated TTO

Continuous for 4 weeks and fever (Temp 37.5°C or more) OR redness/swelling behind the ear, on inside and outside of ear canal — urgent medical consult

• Give amoxicillin–clavulanic acid oral — adult 1750+250mg, child 45+6.25mg/kg up 1750+250mg — doses — twice a day (bd) for 7 days
  
• If allergy — medical consult
• Urgent referral for ENT assessment and refer for hearing assessment

Complicated TTO with bleeding

Bleeding suggests polyp and inflammation — urgent medical consult

• Clean ears and THEN give ciprofloxacin and hydrocortisone (Ciproxin HC) — 5 drops, twice a day (bd) for 7 days
  

If uncomplicated — no fever or associated illness

• Do not give oral antibiotics
• Clean ears with tissue spears
• After cleaning ears give ciprofloxacin — 5 drops, twice a day (bd) for 7 days or until ear dry for 3 days
• Review weekly for 4 weeks
• Keep ear dry (no swimming or wetting) during treatment

Acute mastoiditis

• Rare but can be fatal — infection can spread to brain
• Starts as AOM then becomes infection in mastoid (bone behind ear)

Check

• Head-to-toe exam — with attention to ears
• Tenderness, usually swelling behind ear over mastoid bone — Figure 7.23
• Ear may stick forward at funny angle

Do

• Urgent medical consult to send to hospital
• Put in IV cannula if possible
• Blood cultures before giving antibiotics if possible
• Give flucloxacillin IV — adult 2g, child 50mg/kg/dose up to 2g — doses — single dose
• AND gentamicin IV  — doses — single dose
• If allergy to penicillin — medical consult

Cholesteatoma

• Abnormal cyst (skin growth) in middle ear behind eardrum
• Can occur after repeated infections. May gradually increase and destroy the bones of middle ear
• Consider cholesteatoma if
• CSOM with perforation in attic (upper) area — Figure 7.24
• Granulation tissue or scaly material seen through persistent perforation

Do

• Refer all possible cases to ENT specialist for evaluation and management — must be seen within 1 week
• If in pain — medical consult to send to hospital

Foreign bodies

Do

• Foreign body with pain, fever (Temp more than 37.5°C), bloody pus (discharge) from ear — urgent medical consult
• Never use forceps to remove foreign body — most foreign bodies can be syringed out with warm water
• Before syringing — drown insect with vegetable oil,  lidocaine (lignocaine) 1% or  tetracaine (amethocaine) 1%
• If problems — medical consult

Hearing impairment

• Otitis media causes hearing impairment that ranges from mild to severe
• Hearing loss is often temporary but can become permanent with repeated episodes or persistence of otitis media
• If hearing loss for more than 3 months in both ears
• There is a risk to language development and learning — refer to speech pathologist 
• Refer for rehabilitation including hearing aids, eg Australian Hearing

Hearing tests

• Most newborn babies have hearing screen for nerve deafness before leaving hospital
• Some babies will need further testing at 9 months due to risk factors, eg family history, suspected meningitis, maternal antibiotics in pregnancy
• An audiogram measures hearing in decibels (dBs) at different pitches (frequencies) — used to predict what problems are likely and what assistance may be needed — Table 7.10
• Audiology services will advise what referrals are needed

Supporting resources

• Otitis Media guidelines for Aboriginal and Torres Strait Islander children