The most important skill that needs to be acquired for managing ear problems is assessing the ear drum by otoscope. It is suggested to regularly keep looking at the eardrums of all children. Abnormal tympanic membranes will be automatically detected soon. In line with that, here are 4 cases of ENT issues commonly encountered in children, each with investigation steps and a quick treatment guide.

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Case 1: Acute otitis media (AOM)

A 2-year-old male child weighing 10 kg was brought with excessive crying for 2 days. It was associated with high grade fever. He was not feeding well. There was a history of recent URI a few days back.

Examination

• Right ear- Tympanic membrane was pearly white
• Left ear- Tympanic membrane appeared erythematous and bulging

This was a case of left ear acute otitis media.  

Science behind management

Acute otitis media (AOM) is an acute inflammation of the middle ear by pyogenic organisms (Streptococcus pneumoniae, H. influenza). Commonly, the disease follows a viral infection of the upper respiratory tract which soon invades the middle ear, followed by super-added bacterial infection. In infants <1 year, bottle feeding in a horizontal position can predispose to AOM.

1. Analgesics should be prescribed to reduce the pain.
2. Non-severe AOM with mild pain and mild fever can be observed for 48 hours while severe AOM with severe pain or high-grade fever should be prescribed antibiotics.
3. 1st line of antibiotic treatment is Amoxicillin (80-90 mg/kg/day). Amoxicillin+clavulanic acid is prescribed if the child has already received amoxicillin in the last 30 days.

Treatment

Indication	Drugs & Dosage	Duration & Dosage
Analgesics	Syp. Paracetamol (250 mg/5 ml) Syr. Ibuprofen (100 mg/5 ml)	3ml SOS (15 mg/kg/dose) 5ml SOS (10 mg/kg/dose)
Oral antibiotics (1st line)	Syp. Amoxicillin (250 mg/5 ml); 5 ml – 5 ml – 5 ml	7 days (30 mg/kg/dose)
Alternate (2nd line)	Syp. Cefpodoxime (50 mg/5 ml) 5 ml – 0 – 5 ml	7 days (5 mg/kg/dose)
Intramuscular antibiotic if the child is unable to take oral medication	Inj. Ceftriaxone 500 mg IM	50 mg/kg * 1 dose

Prevention

1. Immunoprophylaxis: Pneumoccocal and H. influenzae immunisation can reduce AOM.
2. Avoiding triggers → Parents should be advised to prevent bottle feeding in a horizontal position and promote breastfeeding.

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Case 2: Otitis externa

A 5-year-old female child was brought with irritability and complaint of pain on touching the right pinna x 1 day. This happened following her swimming class.

Examination

• Right ear- Tympanic membrane pearly white, intact tragus sign positive (tenderness on pressing the tragus)
• Left ear- Tympanic membrane appeared normal, pearly white

This was a case of right otitis externa with intact tympanic membrane.

Science behind management

1. Acute otitis externa presents with itching, pain and fullness due to erythema and oedema of the ear canal and otorrhoea. It is also known as swimmer’s ears.
2. Signs → Tragus sign- Tenderness on moving the pinna/tragus is diagnostic. With or without otorrhoea, tympanic membrane erythema, cellulitis of the pinna, or local lymphadenitis
3. Atiological agents → P. aureginosa, Staphylococcus, Proteus, E.coli, Aspergillus and Candida.

Analgesics, topical antibiotics/antifungals are the first-line of treatment. Addition of topical corticosteroids may resolve symptoms quickly.

Treatment

1. 1st line of treatment is topical antibiotics. Oral antibiotics are reserved for cases in which the infection has spread beyond the ear canal or in patients at risk of a rapidly progressing infection.
2. Antifungals should be given when you suspect fungal otitis externa. 

Indication	Drugs & Dosage	Duration
Topical Antibiotics	Ofloxacin/ciprofloxacin ear drops (Hydrocortisone combination)	2 -2 - 2 - 2 drops * 7 days
Analgesics	Syp. Paracetamol (250 mg/5 ml) Syr. Ibuprofen (100 mg/5 ml)	5 ml thrice a day whenever there is pain 7.5 ml thrice a day whenever there is pain

Prevention

The patient should be advised to-

• Use earplugs while swimming
• Use hair dryer on the lowest setting and head tilting to remove water from the ear canal – after bath or swimming
• Avoid self-cleaning of the ear canal

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Case 3: Impacted wax in children

An 8-year-old child came in with a complaint of itching sensation in the left ear resulting in scratching of the ear canal for 1 week. Recently, the child had also complained of fullness in the left ear. On examination of both ear canals, B/L ear wax was preventing visualisation of ear drum. This was a case of impacted cerumen. 

Science behind management

Cerumen production is a normal process protecting and lubricating the ear canal, but should be removed if symptoms like itching, pain, or decreased hearing present. Cerumenolytic agents used alone or in combination with irrigation or manual instrumentation are the suggested treatment options. Avoid cotton tipped swabs, coconut oil drops. 

Treatment

Prescribe cerumenolytic agents for 2 to 3 days and attempt irrigation/manual instrumentation if still impacted. 

Indication	Drugs & Dosage	Duration
Cerumenolytic	Turpentine oil (15%) + Chlorbutol (5%) + Paradicholorobenzene (2%) + Benzocaine (2.7%)	Fill affected ear 3-5 drops twice daily x 2-3 days
Analgesics	Syp. Paracetamol (250 mg/5 ml) 5 ml	SOS

Referral and advice

1. If you are not confident in performing irrigation refer to otolaryngologist.
2. Avoid traumatic irrigation/manual removal.

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Case 4: Glue ear

Parents bring their 3-year-old boy with recent history of not turning on calling, not turning to bell sounds. Six weeks prior, he had an episode of cold. On examination, both tympanic membranes appear pale yellow, lustreless, bulged out sight of fluid in middle ear without inflammation. This is a case of otitis media with effusion or Glue ear.

Science behind management

Otitis media with effusion (OME) is diagnosed by pneumatic otoscopy demonstrating reduced mobility of tympanic membrane. It is self-limiting. Watchful waiting for three months is recommended before intervening. Age appropriate hearing tests should be done if OME persists for three months.

• For children <4 years- Tympanostsomy tube insertion
• For children >4 years- Tympanostomy + Adenoidectomy; both can lead to improved hearing

Investigations

Tympanometry can confirm pneumatic otoscopy finding.

Treatment

Indication	Drugs & Dosage	Duration
Steriods	Strongly not recommended	-
Antibiotics	Strongly not recommended	-
Antihistamines & decongestants	Strongly not recommended	-

Advice

Parents should be counselled about OME- natural history, need for follow up, and sequelae. 

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This article was originally published in January 2021.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

Dr. Balaji Chinnasami is a Professor of Paediatrics and Medicine at a reputed medical college in Chennai.

Dr. Janani Arul is an Assistant Professor of Paediatrics from Chennai.