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.
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 (see how to hold an otoscope and look in the ear). By looking at the eardrum the examiner can tell if the patient has otitis media (OM) and make an accurate diagnosis (see the pictures of eardrums below).
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. 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. Pneumatic otoscopy can cause discomfort to the patient.
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.
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.
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 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.
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.
Some children with AOM will have ear pain and pull their ears. Other signs of AOM include: fever, trouble sleeping and irritable behavior. However, some children will not have ear pain and will not show any signs of being unwell.
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).
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 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.
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.
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).
AOMwiP should be treated with oral and topical antibiotics such as amoxicillin and ciprofloxacin. CSOM should be treated with topical antibiotics (eardrops) 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 pussy ears should be reviewed every one - 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.
Children with a dry perforation are likely to suffer from moderate to severe hearing loss.
The perforation appears to be dry with no sign of pus near the perforation or in the ear canal.
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.
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 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 for a second opinion. If the child has persistent OME or dry perforation they will need to be referred to an ENT surgeon.
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.
The Clinical care guidelines on the management of OM in Indigenous populations 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.
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.
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).
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.
The Tissue spears: do it right DVD 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.
The Care for kids' ears website contains the following resources recommended for parents and carers:
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.
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 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 (see tissue spears). It is important to ensure that children have had their pneumococcal vaccinations.
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 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.
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 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 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.
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.
The Ear video/DVD 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:
A full set of answers can be found in the Ear video workbook - trainer version.
Images of tympanic membrane 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.
The Diagnostic ear assessment resource - self learning (DxEAR-SL) is designed as a educational exercise to improve abilities to:
practice assessing TMs and get immediate feedback.
The World Health Organisation training resource on primary ear and hearing care 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.
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.
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.
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.