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Primary ear & hearing care

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LEARNING OBJECTIVES

By the end of this module the learner should be able to:

  • Understand the structure of the ear and how it works
  • Recognize common diseases of the middle ear
  • Make and use a dry mop safely to clean the ear canal
  • Make and use a wick to clean the ear discharge from the ear canal
  • Treat acute otitis media
  • Guide people on how to manage a discharging ear
  • Refer patients, when required

 

 

 

TERMINOLOGY

–– Acute otitis media
–– Antibiotic eardrops
–– Chronic suppurative otitis media (CSOM)
–– Dry mopping
–– Dry perforation
–– Eustachian tube
–– Facial palsy
–– Mastoiditis
–– Meningitis/brain abscess
–– Otitis media
–– Perforation
–– Wicking

 

4.1 STRUCTURE AND FUNCTION OF THE MIDDLE EAR

The middle ear is a space deep to the ear drum. It is normally full of air. We can get a view into the middle ear by looking through the ear drum (tympanic membrane) with an otoscope.

Sounds in the ear canal move the ear drum, and these movements are sent through the three bones of hearing to the cochlea of the inner ear. These bones are known as the ossicles, and are called the malleus, incus and stapes.

If the ear drum or the bones of hearing are damaged, this can stop sound getting through. The middle ear also must be full of air for these bones to move properly. There are two main causes of hearing loss related to the middle ear: the ear drum or bones are damaged, or the middle ear is not full of air.

Here are a few other important structures in the middle ear. The middle ear is connected to the back of the nose by a tube called the Eustachian tube, which helps to maintain the pressure in the middle ear. When the tube gets blocked e.g. when one has a cold, it can cause a feeling of blockage and even pain in the ear.

The middle ear is also connected to the mastoid bone, which is the bone behind the pinna. Ear infections can spread into the mastoid bone. If they are severe, sometimes they go through the bone and under the skin behind the pinna. This is called mastoiditis.

4.2 INFECTION OR INFLAMMATION IN THE MIDDLE EAR (OTITIS MEDIA)

The most common problem in the middle ear is infection or inflammation (swelling). This is called otitis media. There are two kinds of otitis media, characterized by the length of the disease – they are explained below.

  • Most ear infections last just a few days. This is acute otitis media. Acute means a problem that has been there for only a short time.
  • Sometimes ear infections lasts for weeks, months or even years. or keep coming back. This is chronic suppurative otitis media. Chronic means a problem that has been there for a long time.

The next two sections describe these different diseases in greater detail.

4.3 ACUTE OTITIS MEDIA

Acute otitis media is an infection of the middle ear.


Who can get acute otitis media?
It often happens in young children but can also occur in older children and in adults.


What happens in acute otitis media?
It often starts with a cold or a sore throat. Infection spreads up through the Eustachian tube from the nose or the throat. The lining of the middle ear becomes infected and this causes fever and pain and the eardrum is inflamed (red). Pus may form and fill the middle ear space. If this happens, the eardrum bulges. If the infection is not treated the eardrum may burst (a perforation) and pus will start to discharge from the ear.

What are the common complaints?

  • Ear pain (otalgia): In case of children, they will say that their ear hurts or pull at their ear. If they are very young they may not be able to say where it hurts, but they will cry
  • Fever: may commonly be present
  • History of cold or sore throat
  • Sometimes, if the ear drum has burst, pus may come out of the ear

WHAT WILL YOU SEE?

Use an otoscope to look at the eardrum.

  • The eardrum will be red and may be a bulging. If the eardrum has burst, you will see a perforated eardrum.
  • Check both ears
  • Check behind both ears for swelling (mastoiditis)

WHAT SHOULD YOU DO?

  • Advise a painkiller, if there is pain or fever
  • Give an antibiotic for 5-7 days if:
  • the ear drum is bulging or has a hole
  • discharge is present
  • temperature is high
  • patient has not started to get better after 2 days
  • Provide antibiotic ear drops ONLY if there is a perforation of the eardrum (refer practical E)
  • Make sure you see the child again after 2 days and then again after 1 week.
  • Check hearing when infection has cleared

REFER IF THERE IS:

  • Severe persistent headache on the side of infection
  • Drowsiness
  • Vomiting
  • Neck stiffness
  • Swelling behind the ear
  • Infection does not resolve even after 7 days of antibiotic
  • Hearing impairment after infection has cleared

REFER to a medical facility close to you, where a general practitioner, paediatrician or ENT doctor can advise

IMPORTANT: TEACH PATIENTS:

  • How to make dry mop with tissue paper so that they can mop the discharge at home
  • Only clean their ears with a dry mop when the ear is discharging.
  • When the ear is dry it must not be cleaned with a dry mop.
  • A dry mop is not the same as a “cotton bud”.
  • “Cotton buds” must never be used to clean ear canals as they are too big and the cotton wool is wound onto the stick too tightly

 

 

 

 

4.4 CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM)

CSOM is a long-standing infection of the middle ear, usually for longer than 2 weeks.

What happens?
CSOM may be a result of an acute otitis media where the ear drum burst and the perforation did not heal. Some children and adults with a hole in the ear drum get repeated infections. Pus comes out of the ear.

WHAT ARE THE COMMON COMPLAINTS?

  • Discharge from the ear, which may be regular or infrequent
  • Difficulty in hearing, especially in those with CSOM in both ears


Note: Pain is not a common complaint

 

 

 

WHAT WILL YOU SEE?

Use an otoscope to look at the eardrum. If there is pus in the ear canal, dry mop it as shown in Practical D. Check behind the ear for any swelling on the mastoid. Make sure you examine BOTH ears.

  • There may be pus in the ear canal which should be mopped. It may be yellow or green. Sometimes there may be some blood in the discharge. It may have a bad smell.
  • Perforation in the ear drum. This may be small and only in one part of the eardrum or may be big. Note the size

WHAT SHOULD YOU DO?

  • Provide antibiotic eardrops to be used 2-3 times a day for a week. If antibiotics drops are not available, antiseptic ear drops can also be used.
  • Teach patient to keep ear dry and dry mop the ear every time before instilling eardrops.
  • Show and instruct how to instill eardrops. Provide the patient instruction sheet.
  • Advise oral antibiotics ONLY if there is any feature of acute infection such as:
  • Red and inflamed eardrum
  • Blood in discharge
  • Pain
  • See the patient again after 7 days to see if the infection has resolved
  • Check hearing after the ear is dry


Give the person complete instruction on how to use ear drops. You can also print and give the patient sheet to him/her.

REFER IF THERE IS:

  • Persistent discharge even after treatment
  • Foul smell in the discharge
  • Swelling behind the ears
  • Dizziness
  • Facial paralysis
  • Hearing impairment

Community resource can be printed and shared with people. See appendix IV

NOTE: At times treatment does not work, or only works for a short time. If a person often has pus from the ear, an operation to repair the ear drum might be required. A patient with long-standing ear discharge should consult with an ENT doctor.

4.5 DRY PERFORATION OF THE EAR DRUM

Sometimes, you may see a dry perforation in the ear drum. Below are details of this condition.


What happens?
A perforation in the ear drum can be caused by a previous infection, acute or chronic suppurative otitis media. Sometimes it is caused by an injury to the ear.

What are the common complaints?

  • At times there may be no complaints
  • Difficulty in hearing
  • Past history of ear discharge


What will you see?
Use an otoscope to look at the eardrum.

  • Perforation in the ear drum, which may vary in size and location

DRY PERFORATION OF THE EAR DRUM

a) A small hole in the ear drum of a right ear

b) A large hole in the ear drum of a right ear.

WHAT SHOULD YOU DO?

  • Check hearing
  • Instruct the patient to keep the ear dry (refer patient instruction sheet ..)
  • Examine the patient again after three months
  • Ask the patient to come back in case of any discharge or pain


A dry perforation may heal on its own, especially if it is small and the ear is kept dry. However, in case it is not healing, it should be closed by surgery.

REFER IF THERE IS:

  • Hearing impairment
  • Patient develops discharge or pain
  • Perforation remains the same even after 3 months

Refer to an ENT doctor as the patient may require surgery.

4.6 SPREAD AND COMPLICATIONS OF EAR INFECTIONS

There are a variety of complications that can result from ear infections, including spread of the infection to other areas of the body.


Some potential complications are as follows:

  • Sometimes an ear infection can spread into the mastoid bone, and under the skin behind the pinna. This is called Mastoiditis.
  • Meningitis or brain abscess can occur when the infection spreads to the brain.
  • It can spread to the inner ear and cause dizziness or vertigo
  • Infection can affect the facial nerve and cause facial palsy. When the nerve is affected, muscles of the face on the side affected can be paralyzed – this is known as facial palsy.
  • It can cause hearing impairment and deafness due to destruction of the eardrum, ossicles or spread to inner ear.

 

 

 

4.7 MASTOIDITIS

What happens?
The infection spreads to the bone behind the ear causing redness, swelling and collection of pus under the skin.

 

What are the common complaints?
• Pain behind the ear
• Fever
• Discharge from the ear may be present

 

What will you see?
• Swelling and redness behind the pinna
• Often the pus can be felt under the skin, feeling like a bag of liquid.
• There is pain on pressing the bone behind the pinna

Make sure you examine both ears!

What should you do?
Refer urgently to a hospital where the patient can receive prompt care


If there is no hospital or health centre near to where you work,

then you can give antibiotics by mouth, until the child can see a specialist.

 

4.8 TEACH PATIENTS TO CARE FOR THEIR DISCHARGING EARS

Patients with history of discharging ear or those who have a dry perforation MUST avoid entry of water into the ear canal at all times.


This can be done by plugging the ear with a cotton earplug while bathing. Ask them to:

  • Keep the ear dry at all times. Avoid swimming, if possible.
  • If they have to swim, this should only be done with a water tight earplug
  • If instructed, put in eardrops at home
  • Clean the ear discharge from the ear canal by dry mopping or wicking before putting in eardrops
  • Come back to see you after a week
  • See a doctor for a full assessment

4.9 ACTIVITIES

 Examining the eardrum (Activity 7- 11)

4.10 VIDEOS

 Revision - sound transmission

 Revision - anatomy of external and middle ear

 Revision - tuning fork tests 

 Suppurative otitis media - consequences and complications

 Pathophysiology of chronic suppurative otitis media

4.11 ATLAS OF PICTURES

 MIDDLE EAR

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