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Care priority and warning signs
Care priority
Routine Management / Treat with Topical Drops
Red flags
- Development of tender swelling behind the ear (Mastoiditis).
- Development of facial weakness.
- Development of vertigo or severe headache.
- Foul-smelling discharge suggesting cholesteatoma.
- Failure to improve after 2 weeks of topical treatment.
Assessment
- Ask: Does the child have an ear problem?
- Ask: Is there ear discharge? If yes, for how long?
- Confirm duration of discharge is 14 days or more.
- Confirm absence of Tender Swelling behind the ear.
- Look: Look for pus draining from the ear.
Classification
- Pus seen draining from ear for >= 14 days AND No tender swelling behind ear -> CHRONIC EAR INFECTION
Key features
- Pus seen draining from ear for 14 days or more.
- Absence of tender swelling behind the ear.
- Requires meticulous ear cleaning (dry wicking) and topical antibiotic ear drops (quinolone).
- Oral antibiotics are generally NOT effective for uncomplicated CSOM.
Management
Non-pharmacological management
- Teach mother how to dry the ear carefully by wicking 3 times daily (as described for AOM). Stress the importance of keeping the ear dry.
- Advise to avoid getting water in the ear during bathing.
Pharmacological treatment
- Treat with topical Quinolone eardrops (e.g., Ciprofloxacin, Ofloxacin - check local availability/guideline) for 2 weeks. Instill drops after dry wicking.
- Check for HIV Infection (refer to HIV assessment algorithm page 8).
- Check for TB (assess symptoms, contact history - see page 9, especially if discharge persists or other symptoms).
Follow-up
- Follow-up in 5 days.
- At follow-up (Day 5): Reassess ear discharge. Check mother's wicking technique.
- If tender swelling behind ear: Treat as Mastoiditis - Refer URGENTLY.
- If discharge persists: Check wicking technique is correct. Encourage mother to continue. Continue eardrops for full 2 weeks.
- If discharge stopped: Praise mother. Advise to finish 2-week course of eardrops.
- If discharge persists after 2 weeks of treatment, refer for further assessment (e.g., ENT specialist).
Counselling points
- Explain the diagnosis (chronic ear infection).
- Emphasize the importance of keeping the ear dry through regular, careful wicking. Demonstrate the technique.
- Teach how to instill the eardrops correctly after wicking.
- Explain the duration of treatment (2 weeks).
- Advise to avoid water entering the ear.
- Advise when to return immediately (swelling behind ear, facial weakness, severe pain, danger signs).
- Advise on follow-up visit in 5 days.
Differential diagnosis
- Mastoiditis
- Acute Ear Infection
- Otitis Externa
- Foreign body with secondary infection
- Cholesteatoma (suspect if discharge persists despite treatment, foul smell, or granulation tissue)
Complications
- Hearing loss (conductive)
- Cholesteatoma formation
- Mastoiditis
- Intracranial complications (meningitis, abscess - less common than with AOM/mastoiditis but possible)
- Facial nerve palsy
Prevention
- Prompt and effective treatment of Acute Otitis Media.
- Immunizations (PCV, Hib).
- Good nutrition.
- Avoiding exposure to smoke.
References
IMCI Chart Booklet - Page 5, Page 8 (HIV), Page 9 (TB), Page 18 (Wicking, Topical Drops details assumed based on text 'Treat with topical quinolone eardrops for 2 weeks'), Page 23 (Follow-up)