Download Keyfacts - Diagnosis and management of ear conditions

Keyfacts - Diagnosis and
management of ear conditions
Ear health workers web resource
How do you diagnose and
manage otitis media with
effusion (OME)?
noticeable. Children with OME will have a type B or C tympanogram
and the eardrum will not move very well with pneumatic otoscopy.
If a child has a single episode of OME it is called ‘episodic’ OME. If
a child has had OME for more than 3 months it is called ‘persistent’
OME.
Tr e a t m e n t
Features
Children with OME will have some hearing loss. They may not
respond when they are called or hear quiet sounds. Sitting close to
the television may also be another sign of hearing loss in children
with OME. Other signs of OME include: balance problems, delayed
speech development, behavioural problems and difficulty at
school.
Diagnosis
OME is characterised by an eardrum that looks retracted or ‘sucked
in’. This occurs because of negative pressure in the middle ear.
Sometimes you can see fluid or bubbles in the middle ear. The
malleus bone (small bone in the middle ear) might also look more
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Children with episodic OME do not need treatment, however they
should be seen again in 3 months time. Infants with persistent OME
(> 3months) may be given long term antibiotics. Older children
with persistent OME are not normally given long term antibiotics
due to concerns of bacteria becoming resistant to treatments.
Infants and children with persistent OME should be referred to a
speech pathologist, an audiologist and ear, nose and throat (ENT)
specialist. Children over the age of 3 years with significant hearing
loss can be fitted with hearing aids or treated with grommets. More
is written below about grommets and other surgical procedures
used to treat OME.
How do you diagnose and
manage acute otitis media
(AOM)?
How do you diagnose and
manage a wet perforation?
Features/symptoms
Features/symptoms
Some children with AOM will have ear pain and pull their ears.
Other signs of AOM include: fever, trouble sleeping and irritable
behavior. Many Indigenous children will not have ear pain and will
not show any signs of being unwell.
Diagnosis
AOM is characterised by a bulging red eardrum. Children with AOM
will have a type B or C tympanogram and the eardrum will not
move very well with pneumatic otoscopy. Medical records need
to be reviewed. If the child has had 3 or more episodes in the last
6 months or 4 or more episodes in the last 12 months they have
‘recurrent AOM’ (rAOM). If a small (pinhole) perforation is detected
on a bulging or red drum the child has AOM with perforation
(AOMwiP).
Tr e a t m e n t
Children will AOM will need to take oral antibiotics (i.e. amoxicillin)
for at least 7 days and be reviewed in 7 days’ time. Infants with rAOM
will need to take antibiotics for 3-6 months to stop perforations
occurring. Children with AOMwiP need to take oral and topical
antibiotics and be reviewed weekly till the ear discharge is gone
and the perforation heals. Children with ear pain can be given
ananalgesic such as paracetamol.
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Children with a wet perforation have ear discharge (pus) that can
often be seen in the ear canal with the naked eye. A child with a
wet perforation may have moderate to severe hearing loss.
Diagnosis
If pus has been present for less than 6 weeks the correct diagnosis
is acute otitis media with perforation (AOMwiP). If pus has been
present for more than 6 weeks the correct diagnosis is chronic
suppurative otitis media (CSOM).
Tr e a t m e n t
AOMwiP should be treated with oral and topical antibiotics such
as amoxicillin and ciprofloxacin. CSOM should be treated with
topical antibiotics only. Wet perforations need to be mopped and
cleaned with tissue spears before eardrops can be applied. This
should occur twice daily until the pus disappears. Families should
be shown how to make tissue spears and perform tragal pumping
(applying pressure to the outer ear to help deliver ear drops deeper
into the ear canal). A sample (culture) of the pus inside the middle
ear or as close to the perforation as possible needs to be collected
for the pathology lab. Children with runny ears should be reviewed
every one to two weeks until the pus clears. If the child has CSOM
for more than three months they should be referred to an ENT
specialist and an audiologist.
Keyfacts - Diagnosis and management of ear conditions
How do you diagnose and
manage a dry perforation?
assess the progress of the ear infection and appropriate treatment
required at subsequent examinations. If there is doubt about the
diagnosis video images should be sent to a doctor or specialist for
a second opinion. If the child has persistent OME or dry perforation
for more than 3 months they will need to be referred to an ENT
surgeon.
What is tympanometr y?
Diagnosis
Tympanometry is used to see if the middle ear works. It is not a
hearing test. When a child has a tympanometry test a small probe
is placed in their ear canal to create an air-tight seal. The probe
contains a tiny speaker, a microphone and an air pump. The air
pump changes the air pressure in the ear canal. The speaker plays a
tone which changes in frequency (pitch) and in intensity (loudness).
Some of the sounds produced by the speaker will travel through
the middle ear and some of the sound will bounce back (reflect) off
the eardrum. The microphone measures the amount of reflected
sound in the ear canal. How well the eardrum moves indicates how
well the middle ear responds to sound. When the eardrum moves
it changes the air pressure in the canal. These changes are recorded
by the tympanometer.
The perforation appears to be dry with no sign of pus near the
perforation or in the ear canal.
What is video-otoscopy?
Features/symptoms
Children with a dry perforation are likely to suffer from moderate
to severe hearing loss.
Tr e a t m e n t
Children with a dry perforation do not need antibiotic treatment.
However, they need to be reviewed in 3 months time to make sure
the pus has not reappeared. Hearing aids and speech therapy can
be used to help reduce the effects of hearing loss. When the ear
has been dry for more than 3 months myringoplasty (operation to
repair the ear drum) is performed to close the perforation.
What are some practical ways
health services can improve the
diagnosis of OM?
Effective medical treatment depends on accurate diagnosis.
Practitioners need to be able to tell the difference between OME,
AOM, AOM with perforation, CSOM and dry perforation. Accurate
diagnosis should be made with a video otoscope, tympanometer
and pneumatic otoscope. Medical records need to be reviewed and
children will need to be followed up regularly to establish if the
condition is episodic, recurrent or persistent. Accurate diagnosis
is dependent on thorough note taking. This involves recording
the position and size of the perforation, the degree, colour and
consistency of discharge, the condition of the eardrum (scarring,
translucent, opaque) and the visibility of fluid or air bubbles
behind the eardrum. The more detail documented the easier it is to
An otoscope is held in the hand and is like a small magnifying glass
with a light to look inside the ear. When otoscopes are attached
to a computer with a screen they are called video-otoscopes. To
examine a child with a video-ostoscope the pinna (outer ear)
is pulled up and back to straighten the ear canal. The examiner
then eases the otoscope through the ear canal gently until a clear
picture of the eardrum can be seen on the screen. By looking at the
eardrum the examiner can tell if the patient has otitis media (OM)
and make an accurate diagnosis. The pictures above were taken
with a video-otoscope.
What is pneumatic otoscopy?
The pneumatic otoscope is an instrument that allows the
examiner to see if the eardrum moves when pressure in the ear
canal increases, like when sound travels through the ear. When
the eardrum is intact but does not move or moves very slowly the
patient is likely to have OM with effusion (OME). The pneumatic
otoscope is like an otoscope only it is attached to a small air-pump
which is a balloon on the end of a hose. When the otoscope part
is inside the ear the balloon is squeezed and a puff of air enters
the ear canal. The examiner then watches to see if and how the
eardrum moves. Pneumatic otoscopy can cause discomfort to the
patient.
http://www.healthinfonet.ecu.edu.au/earworkers
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What is telemedicine?
How do I make tissue spears?
Telemedicine is a process that allows health workers, nurses and
doctors in remote areas to send pictures or videos of eardrums to
specialists either live or via email for recommendations on diagnosis
and treatment. Telemedicine saves a lot of time for patients who
might have had to wait months to see a visiting specialist in their
community.
The Tissue spears: do it right DVD - http://www.healthinfonet.ecu.
edu.au/key-resources/promotion-resources?lid=16457 - resource
shows health personnel and families how to clean pus out of the
ear using tissue spears. Diagrams, images and short videos are
used to demonstrate. This resource should ideally be used by
health professionals with clients and families so that they can help
them understand some of the more complex ideas portrayed.
Why do the guidelines
recommend ciprofloxacin drops
for CSOM instead of sofradex?
The Clinical care guidelines on the management of OM in Indigenous
populations - http://www.healthinfonet.ecu.edu.au/key-resources/
promotion-resources/?lid=22141 - recommend ciprofloxacin for
CSOM instead of sofradex as there is a very small risk of ototoxicity
(damage to the cochlea) from the active ingredients of sofradex refer to comparative trials referenced in the guidelines.
Can I still use sofradex?
Sofradex should only be used for infections in the external canal,
i.e. otitis externa/swimmer’s ear/tropical ear (when the eardrum is
intact), but not for CSOM.
When can/should I syringe the
ears?
Ears can be syringed if there is profuse pus present in the canal or a
foreign body such as an insect. Also, syringe to remove profuse soft
wax or after using eardrops to soften impacted wax (if the eardrum
is known to be intact).
How else can I clean discharge,
wax or foreign bodies from the
ears?
Impacted wax may need to be softened with eardrops, e.g. cerumol,
waxsol, or a solution of bicarbonate of soda. Dry or soft wax and
some foreign bodies can be removed with alligator forceps or
a wax loop using a head-light or other illuminating/magnifying
instrument. Tissue/toilet paper spears are the method of choice
for families to remove pus discharge before putting in eardrops.
If available in the clinic, suction can be used. Cotton buds are not
effective for removing wax or discharge - they are too fat and not
sufficiently absorbent.
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What resources can I use to
improve my diagnostic skills?
Ear video/DVD
The Ear video/DVD - http://www.healthinfonet.ecu.edu.au/keyresources/promotion-resources?lid=14985 - was designed to
assist health staff who are conducting ear examinations on young
children to diagnose and manage the many forms of OM.
Four images of different types of OM are presented in the video
with diagnoses and recommended treatments.
Health staff can work through a further 30 images of the ear and
respond in a workbook to four questions:
• which ear is it?
• what can you see?
• what’s your diagnosis?
• how would you treat it?
A full set of answers can be found in the Ear video (http://
www.healthinfonet.ecu.edu.au/key-resources/promotionresources?lid=14985) workbook - trainer version.
Images of tympanic membrane
Images of tympanic membrane - http://www.healthinfonet.ecu.
edu.au/key-resources/promotion-resources?lid=17286
are
available on the EarInfoNet. The video images are of the tympanic
membrane during the various diagnoses of OM as well as one
of a normal tympanic membrane. These can be used to assist in
diagnosis of OM.
Diagnostic ear assessment resource self learning and assessment
The Diagnostic ear assessment resource - self learning - http://
www.healthinfonet.ecu.edu.au/key-resources/promotionresources?lid=19346 - (DxEAR-SL) is designed as a educational
exercise to improve abilities to:
Keyfacts - Diagnosis and management of ear conditions
• practice assessing TMs and get immediate feedback.
What are the four main priority
groups medical staff should
focus on?
Wo r l d H e a l t h O r g a n i s a t i o n t r a i n i n g
resource on primar y ear and hearing
care
1) Children under three years of
age with discharging ears (wet
perforation)
The World Health Organisation training resource on primary ear and
hearing care - http://www.healthinfonet.ecu.edu.au/key-resources/
promotion-resources?lid=14988 - comprises four training manuals
(basic level, intermediate level trainer’s manual, intermediate level
student’s workbook, advanced level). The resources equips primary
level health workers and communities with simple, effective
methods to reduce the burden of ear and hearing disorders. The
manuals include some very clear otoscopy images.
It is important to identify children with discharging ears early
and make sure they receive appropriate antibiotic treatment. To
improve diagnosis practitioners need to check medical records to
see how long the child has had discharging ears. It is important to
know the difference between AOMwiP and CSOM as they require
different treatments. Regular weekly check ups will need to be
organised to monitor the progress of the ear infection and make
sure families are complying with treatments. Families may need
instruction on how to clean ears with tissue spears before applying
eardrops and why this practice is important. It is important to
ensure that children have had their pneumococcal vaccinations.
• assess tympanic membrane (TM) findings (colour, mobility,
position, translucency and other conditions)
• diagnosis TMs for acute OM, OM with effusion or no effusion
What are grommets?
Children with ‘persistent’ OME or rAOM may be treated with
grommets. Grommets (typanostomy tubes) are small plastic tubes
that are inserted into the eardrum to let fresh air flow into the
middle ear so that the infection can dry up and heal. Grommets
also make the pressure on the inside and the outside of the ear the
same. Grommets usually remain in place for 3 to 9 months. They
usually come out of the eardrum by themselves when the infection
has healed. Children should be reviewed every 3-6 months when
the tubes are in place.
What is a myringoplasty?
Myringoplasty is an operation that is performed to repair holes
(perforations) in the eardrum. Material is ‘grafted’ over the hole
and gradually the eardrum grows over. The ‘graft’ material is a small
bit of tissue or cartilage which is taken from the patient. Grafts are
usually taken from behind or in front of the ear. Children who have
had myringoplasty may have blood stained pus draining from their
ear for up to 4 weeks. If the discharge becomes smelly the child
should see a doctor.
What is an adenoidectomy?
Adenoids are mounds of soft tissue located at the back of the
nose, where the nose meets the throat. Adenoids attract bacteria
and can cause lots of mucous when they become infected. They
can become inflamed and sometimes cause breathing problems.
Sometimes adenoids are removed to stop the production of
mucous and ear infections reoccurring.
2) Children under 10 years who have
hearing loss > 25dB and speech and
communication problems
It is important that this group of children receives medical
treatment, speech therapy and audiological support. Parents
should be encouraged to participate in their child’s learning and
language development. Parents also need to be aware of ways
to communicate more effectively with children with hearing loss
i.e. speak face to face. Parents also need to be aware of situations
where a child’s listening may be affected i.e. people talking in the
background. Effective medical treatment depends on accurate
diagnosis. Practitioners need to be able to tell the difference
between OME, rAOM, CSOM and dry perforation. Accurate
diagnosis should be made with a video otoscope, tympanometer
and pneumatic otoscope. If there is doubt about the diagnosis
video images should be sent to a doctor for second opinion. If the
child has persistent OME or dry perforation they will need to be
referred to an ENT surgeon.
3) Children 3 -10 years old who have
discharging ears
It is important to know the difference between AOMwiP and CSOM
as they require different treatments. AOMwiP is treated with oral
and topical antibiotics, whereas CSOM is treated only with topical
antibiotics. To improve diagnosis a video otoscope should be used
and medical records will need to be reviewed. It is important that
the size and position of the perforation is documented as well as
the duration of discharge. Regular weekly check ups will need
http://www.healthinfonet.ecu.edu.au/earworkers
5
to be organised to monitor the progress of the ear infection and
make sure families are complying with treatments. Families may
need instruction on how to clean ears with tissue spears before
applying eardrops and why this practice is important (see tissue
spears). Children with CSOM need to have antibiotic eardrops till
the discharge has cleared up this can take months. During this time
children will need audiological reviews.
4) Children over 10 years old with
persistent OME, dr y perforations or
a badly scarred eardrum and hearing
loss >35dB
Children in this group need to be referred to an audiologist, a speech
therapist and an ENT specialist for possible surgery; grommets for
persistent OME and myringoplasty for dry perforation. Children in
this group will require a hearing aid which can be arranged by an
audiologist from Australian Hearing.
young children may need to take oral antibiotics every day for long
periods of time, sometimes months. If the child has runny ears it is
important that his/her ears are cleaned daily with tissue spears and
then eardrops (see making tissue spears). Stopping runny ears can
also take months. Families need to be comfortable with the idea
that stopping ear disease requires lots of patience and persistence.
Are there any resources available
to give to families about ear
disease?
The Care for kids’ ears website - http://www.healthinfonet.ecu.edu.
au/key-resources/promotion-resources?lid=23127 - contains the
following resources recommended for parents and carers:
• a parent and carers brochure on key ear health messages
• a set of memory cards to be used as a fun interactive activity
• colouring-in and dot-to-dot sheets
What are some practical ways
health services can improve the
management of OM?
Effective management of OM requires coordination between health
services and families. Early intervention is extremely important.
Collaboration between local health centres and education services
is recommended to help identify infants and young children at risk
of CSOM. Local health and education staff should also develop
a strategic plan to manage OM in the community. The strategy
should involve coordination with specialist staff (audiologists,
speech therapists and ENT surgeons). Measurable process and
outcome indicators should be devised e.g. the frequency of
children initially assessed, seen at follow-up, referred to specialists
and with resolved ear infections.
Compliance to treatment is essential. Families may need reminders
for visits and assistance with treatments. Rewards for positive
clinical outcomes are recommended. Refrigeration of antibiotics
can be problematic for some families. Alternative options such as:
supervised dosing, use of intramuscular antibiotics, single dose
azithromycin or the use of antibiotic sachets to be made up by
families, can be used.
What important things should
parents know about treating
OM?
Parents should know that different stages of OM are treated with
different antibiotics. To prevent the eardrum from perforating some
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Copyright © 2013 Australian Indigenous HealthInfoNet
• a photobook
• an activity book featuring the characters of Kathy and Ernie.
The resource materials are available to download from the Care for
kids’ ears website and hard copies of the resource materials can be
requested using an online order form.
References and further reading
Darwin Otitis Guidelines Group (2010) Recommendations for clinical
care guidelines on the management of otitis media in Aboriginal and
Torres Strait Islander populations. Darwin: Menzies School of Health
Research
Images
The Michael Hawke Library (http://otitismedia.hawkelibrary.com/
albums.php)
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Professor Neil Thomson
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