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

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL

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

Figure 7.21  

Photos provided by Dr Michael Hawke, Hawke Library.

Figure 7.22  

 

Diagnosing ear problems

Flowchart 7.1   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

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • 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

Figure 7.23  

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

Figure 7.24  

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

Table 7.10   Understanding hearing test results

Supporting resources