On this page
Referral and warning signs
When to refer
Urgent Referral: Mastoiditis. Any child with ear problem AND a General Danger Sign. Acute Ear Infection not responding to antibiotics after 5 days. Chronic Ear Infection that develops mastoiditis.
Red flags
- Tender swelling behind the ear.
- Any General Danger Sign.
- Facial nerve palsy.
- Vertigo.
- Severe headache or altered consciousness (suggesting intracranial complication).
Signs and symptoms
- Ask:
- - Does the child have an ear problem?
- - If yes: Is there ear pain?
- - Is there ear discharge? If yes, for how long?
- Look and Feel:
- - Look for pus draining from the ear.
- - Feel for tender swelling behind the ear (mastoid).
Risk factors
- Young age.
- Upper respiratory infections.
- Daycare attendance.
- Passive smoking.
- Lack of breastfeeding.
- Pacifier use.
- Craniofacial abnormalities.
- Immunodeficiency.
Diagnosis
Clinical assessment
Assessment based on presence of ear pain, ear discharge (duration), and tender swelling behind the ear.
Investigations
- Clinical examination is primary.
- Otoscopy (visualization of tympanic membrane) - performed at higher levels, helps differentiate Acute Otitis Media (AOM) from Otitis Media with Effusion (OME) or normal ear.
- Culture of ear discharge (if chronic or not responding).
Diagnostic criteria
IMCI Classification based on signs: - Mastoiditis: Tender swelling behind the ear. - Acute Ear Infection (AOM): Ear pain OR Pus draining from ear for <14 days. - Chronic Ear Infection (CSOM): Pus draining from ear for >=14 days. - No Ear Infection: No ear pain and no discharge.
Management
Non-pharmacological management
- All Ear Infections with Discharge: Teach mother how to dry the ear by wicking (using rolled absorbent cloth/gauze) at least TID.
- Advise mother on home care (pain relief, completing antibiotics), danger signs, and when to return.
Pharmacological treatment
- Mastoiditis:
- - Give FIRST DOSE pre-referral antibiotic (Ampicillin 50mg/kg IM + Gentamicin 7.5mg/kg IM OR Benzylpenicillin 50,000 IU/kg IM).
- - Give Paracetamol 10-15 mg/kg for pain.
- - Refer URGENTLY to Hospital.
- Acute Ear Infection (AOM):
- - Give oral Amoxicillin DT 40 mg/kg PO BID for 5 days.
- - Give Paracetamol 10-15 mg/kg for pain.
- - If discharge present, dry the ear by wicking.
- - Follow up in 5 days (reassess, check adherence, refer if worse/persistent discharge/pain).
- Chronic Ear Infection (CSOM):
- - Dry the ear by wicking.
- - Instill Ciprofloxacin ear drops (0.3%) 1-2 drops TID for 3 weeks.
- - Follow up in 5 days (check technique, reinforce wicking, refer if mastoiditis develops). Continue drops for full duration.
- No Ear Infection: No specific treatment needed for ear.
Monitoring
Follow-up as per classification (5 days for AOM/CSOM). Reassess symptoms (pain, discharge), check ear drying technique, check adherence. Refer if not improving or complications develop.
Complications
- Mastoiditis.
- Hearing loss (conductive or sensorineural).
- Tympanic membrane perforation.
- Chronic Suppurative Otitis Media (CSOM).
- Intracranial complications (meningitis, brain abscess - rare).
Prevention
- Immunization (PCV, Hib, Influenza).
- Exclusive breastfeeding.
- Avoiding exposure to tobacco smoke.
- Good hygiene (handwashing).
Patient education
- Diagnosis (type of ear infection).
- How to give oral Amoxicillin or Paracetamol correctly.
- How to dry the ear by wicking if discharge present.
- How to instill ear drops if prescribed (CSOM).
- Importance of completing full course of antibiotics/ear drops.
- Need for follow-up.
- Danger signs requiring immediate return.
Uganda-specific notes
Ear infections are common. Differentiating AOM from CSOM based on duration of discharge is key for management. Ear wicking is an important skill to teach. Amoxicillin remains first-line for AOM. Ciprofloxacin drops are used for CSOM.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 17, Section 17.3.5
- IMCI Chart Booklet, MOH Uganda
(Ear Problem Algorithm)