Ear Health Protocol Common Ear Problems

Conditions and Management

Acute otitis media +/- perforation (AOM):
Definition: All forms of inflammation and infection of the
middle ear. Usually with pain (though not always), fever,
malaise and hearing loss. Ear drum is red, sometimes
bulging, sometimes with small perforation and discharge.
Can be viral or bacterial.

Recurrent otitis media (ROM)

Definition: 3 or more episodes of AOM in 6 month period.

Management:

Management:

Amoxycillin** 25mg/kg/dose (max 1g/dose) PO twice

dailyfor 7 days. While amoxycillin is preferred as first
line therapy, if there are concerns regarding adherence
to a week long course, an acceptable alternative is a
single dose of oral azithromycin 30mg/kg (up to 1g
maximum) stat*.

Remove any pus from canal by dry mopping with tissue

spears and syringing with dilute betadine see Box 1.

Review at 5-7 days if still discharging pus, increase

dose of amoxicillin** to 45mg/kg/dose (max 1 g/
dose) PO twice daily for further 7 days. **If allergic to
penicillin, use cefaclor. If compliance issues still present
an acceptable alternative is a second dose of oral
azithromycin 30mg/kg (up to 1g maximum) stat.*

Review at day 14 if still unwell with pain and malaise,

stop amoxicillin and change to septrin. If child is well
but discharge still present, treat for CSOM.
Review at 1 month - if still unwell and no response to
treatment, discuss with GP and consider urgent transfer
for ENT review for possible myringotomy and grommits.
Give paracetamol 15mg/kg/dose PO no more than 4
times in 24 hrs for pain relief if needed.

Long term antibiotics to prevent recurrent infections

amoxycillin 15mg/kg/dose (max 1g/dose) PO twice
daily for 3 months . Although amoxycillin is preferred
as first line therapy, if there are concerns regarding
adherence to this regimen, an acceptable alternative is
oral azithromycin 10mg/kg/dose, given once a week for
3 months.

Review at least monthly while on antibiotics to check

for break through infections

Perform screening audiometry and refer for formal

Audiology assessment if abnormal

ENT referral if infections occur while taking antibiotics

as myringotomy and grommets may be needed.

Chronic suppurative otitis media (CSOM)

Definition: Middle ear infection with pus discharging and
hole in the drum (which may be hard to see) for more than
2 weeks

Box 1

Instructions for dry

mopping and syringing

Dry mopping: roll tissue to create tissue spear. Place

gently in ear. Leave for about 20 seconds and rotate.
Remove and repeat until clear.
Syringing: use diluted Betadine (1:20) or sterile water.
Fill a 50ml syringe, attach 1-2cm of soft tubing (eg cut off
butterfly giving set) and gently syringe the ear, pointing
towards the top of the ear canal. Use container to catch
water. Gentle pressure is the key.

Box 2

Instilling Ear Drops in CSOM

Fill the ear with ear drops and apply pressure to the tragus
of the ear to pump the drops through the perforation
into the middle ear. This mechanical flushing technique is
essential to get drainage and aeration of the middle ear.

Dry perforation

Management:

Definition: Perforation for more than 2 weeks with no pus

or fluid.

Keep canal clean see Box 1.

Management:

Ciprofloxacin ear drops (without steroid) fill the ear

with 5 or more drops in the ear twice daily see Box 2.

Watch closely for 3 months

Review at day 7, if ear still discharging pus, continue

dry mopping/syringing and give ciprofloxacin drops in
the clinic under supervision for another 7 days.

Advise parent/carer to bring child to clinic if any

discharge, pus, ear pain

Keep ears dry. Dry mop after shower or swimming

Refer to both audiologist and ENT specialist if

perforation persists after 3 months as ear drum may
need repair.

Review at day 14 if ear is still discharging pus, stop

antibiotics for 2 days then send a swab of the ear
pus to the laboratory for MC&S and discuss results
with ENT. Then continue dry mopping/syringing and
antibiotic drops based on ear swab results under
supervision for up to 2 months.
Review at 2 months - if ear is still discharging despite
treatment THEN refer to audiologist and ENT specialist
for hearing test and possible surgery. Sometimes ears
dont dry up because of cholesteatoma. Continue
treatment while awaiting ENT review

Otitis media with effusion (OME or glue ear)

Definition: Fluid present for more than 6 weeks behind ear
drum (in the middle ear) with no signs of infection. Immobile
drum on pneumatic otoscopy or type B tympanogram.

*Azithromycin is not currently licensed for use in children under six

months of age.

Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley

VC - Last Modified: July 11, 2012 9:05 AM

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Ear Health Protocol Common Ear Problems

reviewing ear swab results.

Impetigo of the pinna

For suspected fungal infections, remove debris with

syringing and use otocomb otic drops 4 drops twice
daily for 7 days.

Definition: A skin infection caused by Staphylococcus

aureus or Group A Streptococcus and presents as crusted
lesions/sores or, less often, blistering on the pinna of the ear.

For fungal infections with Tympanic Membrane

perforation clean outer ear with Betadine (1:20)
followed by Locacorten-vioform ear drops, 3 drops 3
times a day for 7 days.

Management:

Management:

Do a hearing test. If loss >30db encourage regular

valsalvas/popping ears every day.

Review and repeat hearing test after 3 months. If

hearing loss still >30db THEN refer to audiologist and
ENT specialist for possible myringotomy/grommets.
Also refer if ear drum has severe retraction.

Consider antibiotics at 3 months if patient is at high

risk of hearing loss, after discussion with GP/ENT
specialist. Use amoxicillin 25mg/kg/dose (max 1g/dose)
PO twice daily for 4 weeks while awaiting ENT review.

Otitis externa
Definition: Infection of the ear canal with intact drum. This
can be bacterial, viral or fungal. Fungal otitis externa (or
tropical ear) may arise de novo or secondary to antibacterial
ear drop use. It appears as wet newspaper debris in the
ear canal. White fungus is usually Candida albicans and
black fungus is Aspergillus niger.

Management:

Mastoiditis
Definition: Infection within the mastoid process (the bulge
in the skull behind the ear) causing dull ache and tenderness
with associated redness and swelling of the mastoid process
and the ear.

Management:
Discuss with GP and consider urgent transfer for ENT review.
Commence oral antibiotics after discussion with doctor.

Cholesteatoma

Clean ear canal careful dry mopping / gentle

syringing if child allows (remember: often very painful)

Give paracetamol 15mg/kg/dose PO, no more than 4

times in 24 hrs for pain relief if needed.

Definition: Skin growing through a perforated ear drum

into the middle ear or an accumulation of dead skin within
a retracted pocket of the eardrum. This can erode adjacent
bone, leading to hearing loss. It can also erode into the
inner ear and intracranial structures causing meningitis,
brain abscess and death.

Collect an ear swab for MCS and fungal culture.

Management:

For suspected bacterial infections, commence

ciprofloxacin ear drops, 2 drops 3 times a day for 7
days.

Discuss with GP and refer urgently to ENT surgeon for

review.

For more severe infections (eg high fever, very swollen

ear canal, redness around the ear, tender lymph nodes
behind the ear):

Consider alternative diagnosis such as mastoiditis

Insert a wick (preferably a pope otowick) coated with

kenacomb so it slips into ear canal. Use ciprofloxacin
drops every 2 hrs for 3 days. Then remove wick and
continue drops 3 times daily for 1 week.

If patient in severe pain, discuss with GP and consider

stronger analgesia (codeine or morphine).

Keep ear dry (no swimming) while canal is still infected

Review on day 2 and day 7 to make sure infection is

settling. If not, discuss with GP and consider changing
antibiotics to oral ciprofloxacin or IV gentamycin after

Clean with regular soap and warm water daily. Remove

crusts after softening with vegetable or baby oil
overnight.

If there are more than 6 sores, give a single dose of

benzanthine penicillin (Bicillin LA 900mg/2.3ml). See
SKIN INFECTIONS PROTOCOL for dosing according to
weight.

Compacted wax
Definition: Hard wax compacted in the ear canal

Management:
Soften wax using ear drops such as Cerumol for 1-2 days,
then attempt to gently syringe ear(s) to remove wax from
canal see Box 1.

References
Gunasekara, H. OConnor, T. Vijaysekaran, S. Del Mar,
Primary care management of otitis media among Australian
children, MJA, Otitis Media Supplement, Volume 191,
Number 9 November 2009
Leach, A. Morris, P. Mathews, J., Compared with placebo,
long term antibiotics resolves otitis media with effusion
(OME) and prevents acute otitis media with perforation
(AOMwip) in a high risk population: A randomised control
trial,
BMC Pediatrics, 2008, 8:23

Chlolesteatoma

Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley

VC - Last Modified: July 11, 2012 9:05 AM

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