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External Auditory Canal Otitis Externa Defenses include cerumen which acidifies the canal and suppresses bacterial growth.
External Auditory Canal Otitis Externa Cerumen prevents water from remaining in canal and causing maceration. External Auditory Canal Otitis Externa-Management Topical antibacterial drops such as Neomycin otic, polymyxin, Quinolone otic Otic steroid drops containing polymyxin-neomycin and a topical corticosteroid. External Auditory Canal Chronic Otitis Externa Duration of infection greater than four weeks, or greater than 4 episodes a year Risks: inadequate treatment of otitis externa, persistent trauma, inflammation or malignant otitis externa.
External Auditory Canal Malignant Otitis Externa Inflammation and damage of the bones and cartilage of the base of the skull Occurs primarily in immunocompromised Most common etiology is pseudomonas aeruginosa.
External Auditory Canal Malignant Otitis Externa Need IV antibiotics Might need surgical debridement. External Auditory Canal Cerumen Impaction Cerumen is produced by apocrine and sebaceous glands in external ear canal.
External Auditory Canal Foreign body Can include toys, beads, nails, vegetables or insects.
External Auditory Canal Foreign body- Management Irrigation is best provided the TM is not perforated Destroy insect with lidocaine or mineral oil. Tympanic Membrane Bullous Myringitis Vesicles develop on the TM second to viral infections or bacterial infection Usually associated with middle-ear infection May extend into canal.
Middle Ear Acute Otitis Media Viral respiratory infections cause inflammation of ET When ET is blocked, fluid collects in the middle ear. The resource may also contain words and descriptions that could be culturally sensitive and which might not normally be used in public or community contexts. The Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations are intended for use by health care professionals who work with Aboriginal and Torres Strait Islander populations. The clinical care guidelines were prepared by the Darwin Otitis Guidelines Group in collaboration with the OATSIH Otitis Media Technical Advisory Group and were published by the Office for Aboriginal and Torres Strait Islander Health (OATSIH). The clinical care guidelines are divided into sections: prevention, diagnosis, prognosis, medical management, audiological management of associated hearing loss, practical considerations in health care delivery, and prioritisation of primary health care services in different settings. Options for viewing content of the guidelines include downloading the complete guidelines, viewing individual sections by clicking on the headings, and accessing pdfs from the bottom of each section.
Prepared by the Darwin Otitis Guidelines Group Associate Professor Peter Morris,1,2 Associate Professor Amanda Leach,1 Dr Pranali Shah,1 Ms Sandi Nelson (AHW),1 Ms Amarjit Anand,3 Mr Joe Daby (AHW),3 Ms Rebecca Allnutt,4 Ms Denyse Bainbridge,5 Dr Keith Edwards3 and Dr Hemi Patel.3 1 Menzies School of Health Research, 2 Northern Territory Clinical School, Flinders University, 3 Northern Territory Department of Health and Families, 4 Australian Hearing and 5 Northern Territory Department of Education and Training.
For the Office for Aboriginal and Torres Strait Islander Health, Australian Government Department of Health and Ageing, Canberra, ACT. The original 'Recommendations for Clinical Care Guidelines on the Management of Otitis Media'1 were directly linked to the Systematic Review of Existing Evidence and Primary Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations (March 2001).2 This updated version is based on the 2001 Guidelines and relevant research studies published since 2001. Our intended users are health care professionals who work with Aboriginal and Torres Strait Islander populations.
Each recommendation has been explicitly linked to the source of the original relevant evidence (type and level) and any evidence ­based guidelines that have made the same recommendation. Each recommendation has been graded according to the most recent National Health and Medical Research Council (NHMRC) grading system 2010.12 Grade A recommendations are based on several level I or II studies with low risk of bias where all studies show consistent results. Body of evidence provides some support for recommendation but care should be taken in its application. Otitis Media with Effusion (OME): Presence of fluid behind the eardrum without any acute symptoms.
Persistent (Chronic) Otitis Media with Effusion: Presence of fluid in the middle ear for more than 3 months without any symptoms or signs of inflammation. Acute Otitis Media (AOM): General term for both acute otitis media without perforation and acute otitis media with perforation.
Acute otitis Media with Perforation (AOMwiP): Discharge of pus through a perforation (hole) in the eardrum within the last 6 weeks.
Recurrent Acute Otitis Media (rAOM): The occurrence of 3 or more episodes of AOM in a 6 month period, or occurrence of 4 or more episodes in the last 12 months. Chronic Suppurative Otitis Media (CSOM): Persistent ear discharge through a persistent perforation (hole) in the eardrum. Dry Perforation: Presence of a perforation (hole) in the eardrum without any signs of discharge or fluid behind the eardrum. Population at High-risk of Persistent (Chronic) OME: In this document, children living with recognised OM risk factors are considered to be a high risk population for persistent OME. Surveillance for Otitis Media: The systematic and ongoing collection, analysis and interpretation of measures of middle ear disease and hearing loss in order to identify and correct deviations from normal. Screening for Otitis Media: Any measurement (completed at a single point in time) that aims to identify individuals who could potentially benefit from an intervention for OM.
Otoscopy: Looking in the ear with a bright light to identify features associated with outer or middle ear disease. Pneumatic Otoscopy: The combination of simple otoscopy with the observation of eardrum movement when air is blown into the ear canal.
Acoustic Reflectometry: A simple, painless and non invasive diagnostic tool for detecting middle ear effusion. Mastoiditis: Infection of the mastoid air cells of the mastoid bone (behind the middle ear). Tympanocentesis: The insertion of a needle through the tympanic membrane in order to aspirate fluid from the middle ear space. Tympanoplasty: A surgical operation to correct damage to the middle ear and restore the integrity of the eardrum and bones of the middle ear.
Adenoidectomy: A surgical operation to remove the adenoid tissue at the back of the nose (near the tonsils).
Mastoidectomy: A surgical operation to remove infected mastoid air cells in the mastoid bone. Hearing loss: Any hearing threshold response outside the normal range that is detected by audiometry. Conductive Hearing Loss (CHL): Hearing loss that results from dysfunction of the outer or middle ear that interferes with the efficient transfer of sound to the inner ear.
Sensorineural Hearing Loss: Hearing loss that results from dysfunction in the inner ear (especially the cochlea).
Screening for Hearing Loss: Any measurement (completed at a single point in time) that aims to identify individuals who could potentially benefit from an intervention for hearing loss. Universal Neonatal Hearing Screening: The use of objective audiometric tests to identify neonates who might have significant congenital hearing loss. Audiometry (Hearing Assessment): The testing of a person's ability to hear various acoustic stimuli. Pure-tone Audiometry: The assessment of hearing sensitivity for pure-tone stimuli in each ear.


Visual Reinforcement Audiometry: A technique that enables assessment of hearing sensitivity in young children from around 6 months to 3 years of age.
Hearing Impairment Classification: A categorisation that describes the degree of disability associated with hearing loss in the better ear.
Any child with permanent or long term (more than 3 months) bilateral hearing loss greater than 20dB in the better ear should be referred to an audiologist for evaluation of hearing and communication needs.
Primary Health Care: Primary health care is a practical approach to maintaining health and making essential health care universally accessible to individuals and their families. Audiologist: An allied health practitioner responsible for the diagnosis and non-medical management of hearing loss and related verbal communication difficulties. ENT Surgeon: A medical specialist trained in advanced diagnostic, medical and surgical interventions for pathologies of the ears, nose and throat.
Good Practice Point (GPP): This recommendation has been applied where no reliable evidence exists directly assessing the impact of the recommendation. Family Education: Discuss the normal language development milestones and the importance of going to the health centre if their child develops ear discharge. Family Education: Advise the family about the likely hearing loss (usually around 25d B) and the need to re-examine the child in 3 months' time (see chronic OME below). Family Education: Advise the family about the likely hearing loss (usually around 25dB) and the need to organise a hearing test if chronic ear disease affects both ears. Family Education: Emphasise the need to take medications as prescribed and that treatment may need to continue for a long time. GPP*: Tell all expectant mothers about the importance of prevention, early detection and treatment of OM for prevention of OM associated hearing loss. GPP: Ensure that information about OM and effective communication strategies for people with hearing loss is available throughout the community. To attend the health centre as soon as possible whenever a child develops ear pain or discharge, particularly if the child is young. Some features of OM (such as ear pain) may be absent, and that regular health centre attendance for ear examinations is recommended. GPP: Encourage mothers to continue breast feeding for at least 6 months to reduce the risk of OM.
GPP: The health practitioner should tell families or caregivers that nasal discharge carries germs (viruses and bacteria) which are responsible for OM. Grade A: Give pneumococcal conjugate vaccination during infancy according to local immunisation schedule to reduce AOM, rAOM and the need for surgery. GPP: Health staff should undertake ear examinations when they do regular child health checks. GPP: Monitor for hearing loss in all children younger than 5 years and in older children at high risk of hearing impairment.
Conductive hearing loss URI symptoms Vomiting, diarrhea Fever TM bulging and erythematous with decreased or poor light reflex. For example, some information may be considered appropriate for viewing only by men or only by women. They are designed to facilitate the delivery of comprehensive, effective and appropriate ear health programs. It results from a synthesis of information derived from a process of explicit searching of the medical literature and critical appraisal. This includes Aboriginal Health Workers, Aboriginal ear health workers, primary care and specialist physicians, nurses, remote area nurses and nurse practitioners, audiologists, audiometrists, speech therapists, and child development specialists (including Advisory Visiting Teachers and Teachers of the Deaf). Episodic OME and AOM can cause a mild hearing loss while there is fluid in the middle ear space. This is quite different from the clinical course described in most well-designed studies involving other children (where spontaneous resolution of disease is common).11 This high natural cure rate has meant that intervention studies are limited in their ability to detect sustained clinical improvement over time. Two main information sources of information have been used: i) evidence-based clinical practice guidelines, evidence summaries, and systematic reviews, and ii) high quality primary research on OM and hearing loss.
The criteria used for identifying clinical practice guidelines that have a high likelihood of scientific validity are shown in Table 6.
There are likely to be other evidence-based documents in the grey literature that we were not able to identify with our search strategy.
The recommendation (a Good Practice Point) reflects the consensus view of the multidisciplinary guidelines group and is based on clinical experience. Active inflammation or infection is nearly always associated with a middle ear effusion (fluid in the middle ear space).
Other terms have also been used to describe OME (including 'glue ear', 'serous otitis media' and 'secretory otitis media'). It is defined as the presence of fluid behind the eardrum plus at least one of the following: bulging eardrum, red eardrum, recent discharge of pus, fever, ear pain or irritability.
Definition of CSOM varies in the duration of persistent ear discharge (from 2 weeks to 12 weeks). Other terms have also been used to describe otitis externa (including 'tropical ear' and 'swimmers' ear'). This will apply to most rural and remote Aboriginal communities where persistent disease and chronic perforation of the eardrum are common. This may include the use of symptoms, signs, laboratory tests, or risk scores for the detection of existing or future middle ear disease. It is also called a 'ventilation tube', a 'PE tube' (pressure equalisation tube), or a 'tympanostomy tube'.
A perforation in this location may be associated with a deep retraction pocket or cholesteatoma.
This may include the use of risk factors, symptoms, signs, electro-acoustic tests or behaviouraI tests for the detection of existing or future hearing loss.
This is done using headphones (air conduction) or via bone conductors (bone conduction).Testing is possible from around 3 years of age.
Hearing impairment classification applies a graded scale of mild, moderate, severe and profound.
Refer to section E for more information about signs, consequences and recommendations of hearing impairment. This will include consideration of suitability for personal amplification or assistive devices. Primary health care happens in local communities in a manner acceptable to the local community and with their full participation.
Their responsibilities include provision of hearing aids and devices, and auditory training. The recommendation reflects the consensus of the multidisciplinary guidelines group and is based on clinical experience.


If hearing loss is 20-35dB, the child will benefit from classroom sound-field amplification and enhanced communication strategies (e.g. AOMwoP (Acute Otitis Media)Bulging of the eardrum or ear pain plus fluid in the middle ear. Recurrent AOM3 or more episodes of AOM in the previous 6 months or 4 or more episodes in the last 12 months. If hearing loss is 20 -35dB the child will benefit from classroom sound-field amplification and enhanced communication strategies.
Discuss the normal language development milestones and the importance of presenting early to the health centre if their child develops ear discharge.
Chronic Dry PerforationPerforation without any signs of discharge for greater than 3 months.
If hearing loss is 20-35dB, the child will benefit from classroom sound-field amplification and enhanced communication strategies. If swimming is known to be associated with new or persistent ear infections in an individual, it is reasonable to recommend keeping the ear dry.
The HealthInfoNet respects such culturally sensitive issues, but, for technical reasons, it has not been possible to provide materials in a way that prevents access by a person of the other gender. Aboriginal and Torres Strait Islander health staff working with Aboriginal and Torres Strait Islander families are likely to have the greatest impact on severe otitis media. It is best to regard OM as a spectrum of disease that ranges from mild (otitis media with effusion, OME) to severe (chronic suppurative otitis media, CSOM).
Chronic disease (persistent OME and CSOM) can cause moderate hearing loss.8,9 Additionally, the hearing loss can fluctuate depending on the health of the middle ear.
For children at high risk of CSOM, we recommend interventions where there is strong evidence of short-term benefit even if the long-term benefits were less clear.
While the recommendations have been based on the best available evidence, their applicability will also be dependent on local factors.
Grade B recommendations are based on one or two level II studies with low risk of bias or a systematic review of level III studies with low risk of bias.
A bulging eardrum, recent discharge of pus, and ear pain are the most reliable indicators of AOM. Importantly, the diagnosis of CSOM is only appropriate if the tympanic membrane perforation is seen and if it is large enough to allow the discharge to flow out of the middle ear space. The World Health Organization has recommended that rates higher than 4% are unacceptable and represent a massive public health problem.
Reduced mobility of an intact eardrum is a good indication of the presence of middle ear fluid.
This type of hearing loss may also occur secondary to dysfunction of any part of the auditory nerve. This is based on degree of deviation from normal thresholds in the 'better ear' as recorded through audiometry. In the first instance, referral would be made to state or territory funded audiological services where available. Primary health care is more than an extension of basic health services and has social and developmental dimensions. Discuss the normal language development milestones and the importance of going to the health centre if the ear discharge does not improve. Discuss the normal language development milestones and the importance of going to the health centre if the ear discharge gets worse.
Discuss the normal language development milestones and the importance of going to the health centre if the child develops ear discharge. The guidelines are also suitable to be adopted for use in local clinical practice guidelines and standard treatment protocols (e.g. In all populations, every child will experience episodic OME (fluid behind the tympanic membrane) at some time.5 Nearly all children will experience at least one episode of acute otitis media (AOM).
CHL is often regarded as a temporary condition because its causes are generally amenable to medical or surgical treatment.
Most important are the personal preferences of the affected individuals, and the local resources available to assist in the management of OM.
A type B tympanogram or reduced mobility of the eardrum on pneumatic otoscopy are the most reliable indicators of OME. In developed countries, most children will improve spontaneously.5 Concerns about OM arise in children who suffer frequent episodic AOM or persistent OME. These local factors should always be considered when developing an ear health program and when advising families about their management options. Grade B recommendations are applicable to the Australian health care context with few caveats. However, hearing loss associated with OM can vary in severity overtime and have a substantial effect upon hearing for frequencies outside those routinely tested. Grade C recommendations are based on Level III studies with low risk of bias or level I or level II studies with moderate risk of bias. It should be noted that azithromycin is not currently licensed for use in children under six months of age]. For Grade C recommendations, some inconsistencies reflect genuine uncertainty around the clinical question. It does not account for the impact of early onset, language, processing ability and environmental factors. If no improvement despite good compliance, consider admission to hospital for IV antibiotic treatment. Grade C recommendations are probably applicable to the Australian health care context with some caveats. Hence, average hearing levels based upon a single assessment could underestimate the degree of impairment.
Grade D recommendations are based on level IV studies or level I, II and III studies with high risk of bias. Grade D recommendations should be applied cautiously in the Australian health care context.



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