Recommendations for clinical care guidelines on the management of Otitis Media in Aboriginal and Torres Strait Islander Populations

Section F-2: Prioritisation of Primary Health Care Services in Different Settings

When resources are limited, focus on those most likely to benefit from the recommendations contained within this document. Develop a health care strategy for your organisation. The strategy should cover prevention, diagnosis and management.

Page last updated: 14 October 2011

When resources are limited, focus on those most likely to benefit from the recommendations contained within this document. Develop a health care strategy for your organisation. The strategy should cover prevention, diagnosis and management.

Priority 1: Children <3 years old with discharging ears

(These children will have either AOMwiP or early onset CSOM.)

The aim of the program is to identify children early, provide appropriate antibiotic treatment, organise weekly follow ups and optimise adherence strategies. This all needs to continue until resolution of discharge is achieved.

Appropriate antibiotic treatment is the key to a better health outcome. Treatment may need to be continued for many months.
Key StepsRecommended Actions
Effective Prevention1) Organise individual or group education sessions to discuss early onset of OM, signs/symptoms of OM and preventive measures to decrease OM and associated hearing loss.

2) Encourage breast feeding, avoidance of passive smoking exposure and reducing exposure to germs (through frequent hand and face washing and drying).

3) Ensure the recommended pneumococcal vaccination is given as per schedule.
Effective Diagnosis1) Ensure accurate diagnosis with otoscope (video otoscope preferred). Document duration of discharge and size (and position) of perforation (if possible).

2) Distinguish between AOMwiP and CSOM by history and review of medical record.

3) Use syringing/suctioning if required to obtain clear view of TM for more accurate diagnosis.

4) Refer (or send video images) for second opinion if there is a doubt about the diagnosis.
Effective ManagementAOMwiP

1) Organise weekly review and update register (local clinic-based recall and reminder systems) of affected children every month.

2) Ensure that high dose antibiotic therapy (amoxycillin or amoxycillin-clavulanate) plus topical ciprofloxacin (2-5 drops 2-4 times a day) after ear cleaning are being given to all children who do not respond oral antibiotics within 4-7 days.

3) Ensure that the ear cleaning is effective and that the antibiotic drops are being pushed through the perforation.

4) Review strategies to improve adherence with recommended treatment.

5) Discuss option of long-term antibiotics with family. This would continue even after the episode of AOMwiP has resolved.

6) Refer for hearing assessment after 3 months or at any time there are concerns.
Early Onset CSOM

1) Organise weekly review and update register (local clinic-based recall and reminder systems) of affected children every month.

2) Ensure that topical ciprofloxacin (2-5 drops 2-4 times a day) is being given after ear cleaning.

3) Ensure that the cleaning is effective and that the antibiotic drops are being pushed through the perforation.

4) Review strategies to improve adherence with recommended treatment.

5) Discuss option of long-term antibiotics with family. This would continue even after the episode of CSOM has resolved.

6) Refer for hearing assessment after 3 months or at any time there are concerns.

7) Discuss option of hospitalisation for parenteral antibiotic administration if no response to topical antibiotic treatment after 16 weeks.
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Priority 2: Children <10 years old who have hearing loss of >25dB (in the better ear) plus speech/language/communication problems

(These children may have any form of OM.)

The aim of the program is to ensure that speech therapy and audiological management occur while medical treatment is optimised.

Appropriate medical treatment requires an accurate diagnosis and regular long-term follow up. A multidisciplinary approach adapted to meet the needs of the child is the key to a better health outcome. These children are likely to need ongoing ear health and hearing monitoring and hearing support throughout childhood.
Key StepsRecommended Actions
Effective Prevention1) Organise individual or group education sessions to discuss early onset of OM, signs/symptoms of OM and preventive measures to decrease OM associated hearing loss.

2) Encourage family to participate actively in learning and language development. Provide support for reading, speaking and writing activities at home.
Effective Diagnosis1) Distinguish between persistent OME, rAOM, CSOM and dry perforation by accurate diagnosis with otoscopy (video otoscope preferred) and tympanometry or pneumatic otoscopy.

2) Review the history and medical record, and preferably document size and position of the perforation (if present). Also document the type and severity of the speech/language/communication problem.

3) Refer (or send video images) for second opinion if there is a doubt about diagnosis.
Effective Management1) Ensure medical management of OM as per guidelines.

2) Review regularly (3-6 monthly).

3) Tell families/caregivers and teachers that children’s listening may be affected in the following situations:
  • being far away from person speaking
  • background or competing noise
  • use of a second language
  • new and unfamiliar speakers
  • new and unfamiliar words or concepts.

4) Recommend preferential sitting and the use of visual cues (lip-reading, body language and hand talk), raised speech volume (amplification) and contextual cues in the classroom.

5) Recommend sound-field classroom amplification and use any amplification devices recommended by the audiologist.
Effective Management
Continued
6) Advise family to participate actively in learning and language development.

7) Repeat hearing tests after 3 months.

8) Refer to an ENT specialist for:
  • grommet insertion for persistent OME
  • myringoplasty for dry perforation.
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Priority 3: Children aged 3-10 years old who have discharging ears

(These children will generally have CSOM.)

Once established, CSOM can be extremely difficult to treat (this is why the Priority-1 is so important).

The aim of the program is to support long-term topical antibiotic treatment combined with appropriate audiological management.

Adherence to the treatment and regular follow up every 1-2 weeks is the key to a better health outcome. Specialist review may be needed if the diagnosis is unclear or if the child does not respond to the treatment.
Key StepsRecommended Actions
Effective Prevention1) Organise individual or group education sessions to discuss the severity of CSOM and associated hearing loss.

2) Encourage family to participate actively in learning and language development. Provide support for speaking, reading and writing activities at home.
Effective Diagnosis1) Ensure accurate diagnosis with otoscope (video otoscope preferred) and medical records and distinguish between AOMwiP and CSOM by history and reviewing medical record. Most children will have CSOM.

2) Document duration of discharge and preferably size (and position) of the eardrum perforation (if possible).

3) Use syringing/suctioning if required to obtain clear view of TM for accurate diagnosis.

4) Refer (or send video images) for second opinion if there is doubt about diagnosis.

5) Refer for hearing assessment.
Effective Management1) Organise 1-2 weekly reviews and updates (local clinic-based recall and reminder systems) register of affected children every month.

2) Ensure that topical ciprofloxacin (2-5 drops 2-4 times a day) is being given after ear cleaning.

3) Ensure that ear cleaning is effective and make sure that the antibiotic drops are being pushed through the perforation.

4) Review strategies to improve adherence with recommended treatment.

5) Consider hospitalisation for parenteral antibiotic if there is no response to topical antibiotic treatment after 16 weeks.

6) Recommend preferential seating and the use of visual cues (lip-reading, body language and hand talk), raised speech volume (amplification) and contextual cues in the classroom.

7) Recommend sound-field classroom amplification and support use of amplification devices recommended by the audiologist.
Effective Management
Continued
8) Advise family to participate actively in learning and language development.

9) Refer to an ENT specialist if the diagnosis is uncertain or there is no response to medical therapy.

10) Refer to speech pathologist if this is indicated.
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Priority 4: Other children aged <10 years old with persistent OM or tympanic abnormality and hearing loss >35dB in the better hearing ear

(These children will generally have persistent OME or a badly scarred eardrum.)

The aim of the program is to provide audiological management for all children and identify those children who will benefit from surgery.

Enhanced communication strategy and appropriate use of hearing aids is the key to a better health outcome.
Key StepsRecommended Actions
Effective Prevention1) Encourage family to participate actively in learning and language development. Provide support for reading, speaking and writing activities.

2) Increase awareness of the education staff about support strategies for children with hearing loss.
Effective Diagnosis1) Make accurate diagnosis by otoscope (video otoscopy preferred).

2) Distinguish between bilateral persistent OME, dry perforation and other TM abnormalities (like scarring or severe retraction).

3) Refer for hearing assessment.
Effective Management1) Recommend preferential seating and the use of visual cues (lip-reading, body language and hand talk), raised speech volume (amplification) and contextual cues in the classroom.

2) Refer for appropriate hearing aid.

3) Recommend effective communication strategies.

4) Recommend auditory training support from speech therapist.

5) Recommend language stimulation and speech correction at home and school.

6) Repeat hearing assessment after 3 months.

7) Refer to an ENT specialist for:
  • grommet insertion for persistent OME
  • myringoplasty for dry perforation.

8) Organise a repeat medical review after 3 months and update register (local clinic-based recall and reminder systems) of affected children regularly.
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