Ear problems

Reading

Please look at the Royal Children’s Hospital Melbourne guideline. (RCH guidelines are some of the
best concise clear guidelines in pediatrics that are evidence based and regularly updated and its
worth downloading their app to use on your phone).
https://www.rch.org.au/clinicalguide/guideline_index/Acute_otitis_media/ This guideline has some
excellent photos. Pay attention to the appearance of the ear drum in ordinary viral fevers which
should not be treated with antibiotics (e.g. A reddish ear drum with hyperemia which is still
transparent and not bulging is NOT acute suppurative otitis media!). You need a red inflamed bulging
ear drum that is no longer transparent. However, in an ideal world it will be easy to see the details of
ear drums on otoscopy in children. In a crying upset child the best technique may only offer you a
glimpse of part of a drum! (Be ready to show how you would strive to get the best view of the ear
canal and drum in a child.) Then, you may need to use your overall clinical judgement. Always check
for other foci of pain or infection before you ascribe fever or pain to otitis media especially of you
cannot see details or if the child has red flags with fever present.

However the RCH guideline is written for a population where the complications of ASOM are low. So
even where there is a red bulging ear drum that is no longer transparent they do not advocate
routine use of antibiotics. In populations where the complication rates of ASOM are high e.g.
perforation of the ear drum (like in poor communities in India where malnutrition and anemia may
affect the course of the disease) then guidelines may need to be different. In Aboriginal Australia the
complications rates of ASOM are very high. Look at a guideline written for them
https://static1.squarespace.com/static/5b5fbd5b9772ae6ed988525c/t/
5fadf8b31cc5cc662254a6a3/1605236925527/Ear+Problems+in+Children.pdf If you can’t open this
file go to Google -> Kimberly Aboriginal Health Planning Forum and click on clinical guidelines ->
Child health -> Ear problems. This guideline may go to the other extreme of advocating long and
frequent use of antibiotics. The need in India may be somewhere in the middle but India has very
few rational guidelines on ear health. If you find one then please share it. Note the use of ear
syringing done gently to get ear toilet in infected ears even if a perforation is present (using ideally 1
in 20 diluted betadine solution and gentle syringing) to get a good view of the ear drum in
discharging ears. This is contrary to usual teaching but is safe.

1. A 2 year old boy has fever runny nose and cough for 3 days. He has had no vomiting or other
localizing signs of infection. He is immunized and has no relevant past medical history. OE
looks unwell T 102F RR 48pm P130 BP80/60 CR 2s Sats 94% Dry tongue, No rash well
nourished You examine his R ear and note it is red and inflamed but not bulging and is
transparent. His throat is normal and the chest is clear No hepatosplenomegaly What is the
diagnosis? How would you manage him?
2. In a 2 year old with acute otitis media of 3 days duration after URI what antibiotic and what
dose and duration would you use? What organism are you treating?
3. If this child was 3 months old and has a discharging ear what else must you look for carefully
on clinical exam? Will the treatment be different? Would you use topical antibiotic and if so
what and how? How will you arrange follow up? (
4. You are seeing a 7 year old child in a school health
check. He has no complaints. You notice that his r
ear has this appearance. He said he remembers he
 used to have discharging ears as a toddler but not now. How would you manage him? Do
discuss with your ENT colleagues in giving an answer.
5. You see a 5y old child who has a history of chronic ear discharge in left ear and who now has
fever and looks unwell. He has no vomiting. GCS 15 T 103F RR 30 P 130 BP 90/60 CR 2s Sats
98% and no neurological signs or neck stiffness. He has a pointing mastoid swelling of 2-3cm
You are in a rural area and the nearest ear surgeon is 40km away and you know there will be
a delay of several hours in reaching the ENT surgeon because the parents want to go home
before travelling to the hospital. You could discuss the case with the ENT surgeon by phone.
What investigations and treatment would you start at the PHC? If there is to be a long delay
in referral would you drain the pointing abscess to relieve pressure within the abscess?
6. A 24 year old man presents with impacted wax in both ears. He is otherwise well but has had
this before. Your health workers have been trained to do ear syringing. State the essential
preparation, patient education and method of syringing in your PHC. If the wax is impacted
and not easily syringed what will you do for a person who has walked a long way to get to
you?
7. A 24 y old has a severely painful left ear for 2 days.
He has no dental or other local sources of pain and
his throat is normal. His vital signs are normal but he
has pain on moving the pinna and otoscopy shows
this. Management in a PHC? Role of systemic
antibiotics?

8. The patient in 7 had put coconut oil in his ear thinking he had wax. If otoscopy showed this

what would management be?

9. In a routine examination of a 6 year old in health
check you notice he has a glue ear. He has no
complaints. What is the pathology behind this?
What should management be?
10. In a school health camp you see a 17 year old with a small amount of smelly discharge in R
ear for many months or even longer.
Management?
11. What steps need to be taken to protect hearing in
older age that need to be implemented in the
young? If a 60 y old man comes with difficulty
hearing what would your approach be in
assessing his hearing loss. What kinds of hearing
aids do you know of?