Ear Problems
Otitis Media
Aetiology: pneumococcus (25%), Hib (25%, in children <6yrs); no bacteria identified (25%); moraxella
catarrhalis (20%), anaerobic bacteria (5%); 30% H influenza and 80% moraxella have beta-lactam
resistance
Symptoms: less common in young children, especially Hib
Examination: high predicitive value: bulging, cloudiness, immobility of tympanic membrane
moderate predictive value: erythema
poor predictive value: retraction of tympanic membrane
Management: give antibiotics if symptoms not improving in 48-72 hours (as this means it’s less likely viral),
unless indications below
Antibiotic efficacy: 85% improve without antibiotics; antibiotics  cure rate by 10% (to 95%),  duration
of fever by 1/7, NNT 9-15; may not change outcome <2yrs, does not affect rates of complications
Indications for immediate antibiotics: indigenous, immunosuppressed, difficult follow up, <2yrs with
bilateral disease, tympanic membrane perforation
Antibiotic choice: Amoxicillin 15mg/kg TDS PO
or Cefaclor 10mg/kg QID PO
or IM ceftriaxone x1
or azithromycin
or augmentin 25mg/kg TDS PO
or cefuroxime if not responding
Complications: middle ear effusion (antibiotics not needed unless acute symptoms present)
Perforation
Temporary conductive hearing loss
Chronic otitis media with effusion ( cholesteatoma, bony destruction of ossicles; usually anaerobic
bacteria)
Suppurative otitis media (perforates tympanic membrane; PO / TOP ciprofloxacin or aminoglycoside)
Mastoiditis (incidence 3/100,000; usually grp A strep or strep pneumoniae; otorrhoea, ear pain,
displacement of ear down/out/forward, mastoid erythema and fluctuance, obliteration of postauricular crease; treat with IV antibiotics (vancomycin / ceftriaxone + cefotaxime, incision and
drainage); may be + periostitis
Intracranial abscess (subdural / extradural; purulent otorrhoea, focal neurological deficit, meningitis; if
temporal lobe – aphasia, visual field defect)
Meningitis
Lateral sinus thrombosis (extends into IJV; R>L; picket fence fever due to intermittent bacteraemia,
headache, papilloedema, vertigo; palpable IJV; cranial nerve palsy VI, IX, X, XI); treat with IV penicillin +
ceftriaxone + metronidazole
Facial nerve paralysis
Pterous apicitis (infection goes medially through temporal bone to trigeminal ganglion and cranial nerve
VI  retroorbital pain, abducens nerve palsy)
Tympanic
Membrane
Perforation
Aetiology: otitis media (usually inferior portion); trauma; barotrauma; cholesteatoma (in superior portion)
Symptoms: pain, hearing loss, discharge, severe vertigo and complete hearing loss (suggests inner ear
involvement)
Management: Infection: do CT if tender mastoid process; refer for myringoplasty if tympanic membrane
not healed by 3/12
Traumatic: remove debris from external ear canal; surgery if >50% surface area involved; if
small, usually heal spontaneously in 6/52; give antibiotics for active infection / scuba
diving related
Cholesteatoma: do CT, refer ENT
Don’t give TOP gentamicin if perforation – use ciprofloxacin instead; advise to keep ear canal dry until
healed
Otitis
Externa
Epidemiology: most common ear infection in adults
Aetiology: pseudomonas > staph aureus > proteus > fungal (10%) (aspergillus in 80-90%; klebsiella,
candida); enterobacter
Symptoms: pain, discharge, conductive hearing loss; tenderness on pinna movement
Management: combined steroid / antibiotic ear drops for 1/52 (eg. Dexamethasone + framycetin +
gramicidin); ciprofloxacin TOP if treatment failure / tympanic membrane perforation / T tubes in situ
Give systemic antibiotics if: fever and systemic symptoms, involvement of pinna, folliculitis; flucloxacillin
12.5mg/kg QID PO for 5/7
Debridement / mopping if: significant debris, ear toilet (gentle irrigation with hydrogen peroxide and
Suctioning
Wick insertion if: mod/severe, replaced Q2days
Daily review until improvement
Malignant otitis externa: invasive form; pseudomonas in >90%; risk factors = diabetes,
immunosuppression; suspect if persistent otitis externa for >2-3/52; may cause otitis media of base of
skull, mastoid air cells, sigmoid sinus, parotid gland  facial paralysis, cranial nerve VII  cranial nerve X,
X, XI; lateral / sigmoid sinus thrombosis, meningitis; do CT; give IV gentamicin 5mg/kg OD + ceftazidime 2g
TDS or ciprofloxacin 400mg BD, admit