Download Ear Health Protocol - Kimberley Aboriginal Medical Services Council

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.
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 septrin. 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.
Recurrent otitis media (ROM)
Definition: 3 or more episodes of AOM in 6 month period.
Management:
•
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
Management:
•
Keep canal clean – see Box 1.
•
Ciprofloxacin ear drops (without steroid) fill the ear
with 5 or more drops in the ear twice daily – see Box 2.
•
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.
•
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
don’t dry up because of cholesteatoma. Continue
treatment while awaiting ENT review
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
Definition: Perforation for more than 2 weeks with no pus
or fluid.
Management:
•
Watch closely for 3 months
•
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.
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.
© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley
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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 kenacomb 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. O’Connor, 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 29, 2011 9:09 AM
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Ear Health Protocol – Algorithm 1; Could the child have a middle ear infection?
Opportunistic and/ or scheduled screening
Presents with symptoms or signs suggesting ear
disease (eg ear pain, ear discharge, irritable, pulls
ears, doesn’t respond to carers and/or teachers
Perform ear questionnaire
Examine ears - pneumatic otoscopy.
Foriegn body
Normal looking ears
but abnormal ear
questionnaire
Bulging ear
drum
Refer to doctor
Refer for formal Audiology
assessment
Follow acute otitis media pathway
Otitis externa
•
Gently clean ear canal (often very painful)
•
Collect an ear swab
•
Ciprofloxacin ear drops, 2 drops 3 times a day for
7 days
•
Keep ear dry
•
Review day 2, day 7 to ensure improvement
•
Discuss with GP and consider changing antibiotics
to oral ciprofloxacin or IV gentamycin after
reviewing ear swab results.
•
For suspected fungal infections, remove debris with
syringing and use kenacomb otic drops 4 drops
twice daily for 7 days.
•
For fungal infections with TM perforation clean
outer ear with Betadine (1:20) followed by
Locacorten-vioform ear drops, 3 drops 3 times a
day for 7 days.
Discharge
Follow runny ear
pathway
Perfotation still present
Refer to Audiology AND
ENT specialist
OME one or both ears
Follow OME pathway
© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley
Dry perforation
Review in 3 months
Advise to keep ear dry and
to return in the meantime
if discharge recurs
No perforation
Perform pneumatic
otoscopy
Normal pneumatic
otoscopy
Follow up according to
usual ear health screening
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Ear Health Protocol – Algorithm 2: Managment of otitis media with effusion
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Otitis media with effusion (OME)
(Diagnosed with pneumatic otoscopy)
Observe for 3 months
Explain that most effusions resolve without treatment
Give communications advice (appendix B)
REVIEW AT 3 MONTHS
Resolution - both ears normal
Follow usual screening protocol
Audiometry normal in ‘good’ ear”
Continue to review every 3 months.
OME in only one ear: Perform
audiometry (or refer to Audiologist
if under 3 years / unable to perform
audiometry)
Audiometry abnormal in “good’ ear
->
Treat as for OME in both ears.
Resolution of OME in one ear only
OME in both ears:
Give Amoxicillin 25mg/kg/dose
(azithromycin 10mg/kg given)
Review after 4 week course of antibiotics Perform pneumatic otoscopy and audiometry (or
refer to Audiologist if under 3 years / unable to
perform audiometry)
Resolution - both ears normal - Follow usual
screening protocol
© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley
Persisting bilateral OME and
/ or unilateral OME with
abnormal audiometry - refer to
ENT specialist
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Ear Health Protocol – Algorithm 3: Management of runny ears
Runny Ears
Less than 2 weeks
Amoxicillin 25mg/kg/dose (Max
1gram/dose) PO BD for 7 days
•
Keep ear canal clean
•
Analgesia as appropriate
•
Review at day 7
Longer than 2 weeks
Treat as CSOM
Treat as for acute Otitis media
•
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Keep canal clean
Ciprofloxacin drops 4 drops into ear BD
Continue for 7 days
Resolution of discharge
perform otoscopy
No resolution at day 7
No resolution at day 7
•
Keep canal clean
•
Supervised ciprofloxacin 4 drops BD
at clinic
Amoxicillin 45mg/kg/dose (Max
1 gram/dose) PO BD for 7 days
Perforation present
Review in 3 months
No perforation
Advise to keep ear dry and
to return in the meantime if
discharge recurs
Perform pneumatic otoscopy
Keep ear canal clean
Analgesia as required
No resolution day 14
No resolution day 14
Follow CSOM pathway
•
Send ear swab for M/C/S
•
Discuss results with ENT team
•
Refer Audiology for consideration of
assistive hearing devices
Review at 3 months
OME one
or both
ears
Normal
pneumatic
otoscopy
Perforation still present
Follow
OME
pathway
Follow up
with usual
schedule for
ear health
screening
Refer to Audiologist AND
ENT specialist
© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley
VC - Last Modified: July 29, 2011 9:09 AM
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