child is at high risk of serious complications (e.g. in
immunosuppression, cysticfibrosis), if mastoiditis is
present, or in children under 2 years of age with bilateral
otitis media. Perforation of the tympanic membrane in
children withacute otitis mediausually heals spontaneously
without treatment; if there is no improvement, e.g. pain or
discharge persists, a systemic antibacterial can be given.
Topical antibacterial treatment of acute otitis media is
ineffective and there is no place for ear drops containing a
local anaesthetic.
Otitis media with effusion
Otitis media with effusion (glue ear) occurs in about 10 %of
children and in 90 % of children with cleft palates.
Antimicrobials, corticosteroids, decongestants, and
antihistamines have little place in the routine management
of otitis media with effusion. If glue ear persists for more
than a month or two, the child should be referred for
assessment and follow up because of the risk of long-term
hearing impairment which can delay language development.
Untreated or resistant glue ear may be responsible for some
types ofchronic otitis media.
Chronic otitis media
Opportunistic organisms are often present in the debris,
keratin, and necrotic bone of the middle ear and mastoid in
children with chronic otitis media. The mainstay of
treatment is thorough cleansing with aural microsuction,
which may completely resolve long-standing infection.
Cleansing may be followed by topical treatment as for otitis
externa; this is particularly beneficial for discharging ears or
infections of the mastoid cavity. Acute exacerbations of
chronic infection may require treatment with an oral
antibacterial; a swab should be taken to identify infecting
organisms and antibacterial sensitivity.
In view of reports of ototoxicity, manufacturers
contraindicate topical treatment with ototoxic antibacterials
in the presence of a tympanic perforation or patent
grommet. Ciprofloxacin or ofloxacin p. 677 eye drops used in
the ear [unlicensed use] or ear drops [both unlicensed;
available from‘special-order’manufacturers or specialist
importing companies] are an effective alternative to such
ototoxic ear drops for chronic otitis media in patients with
perforation of the tympanic membrane.
However, some specialists do use ear drops containing
aminoglycosidesorpolymyxins[unlicensed indications]
cautiously in children with chronic suppurative otitis media
and perforation of the tympanic membrane, if the otitis
media has failed to settle with systemic antibacterials;
treatment should be considered onlyby specialistsin the
following circumstances:
.drops should only be used in the presence of obvious
infection;
.treatment should be for no longer than 2 weeks;
.the carer and child should be counselled on the risk of
ototoxicity and given justification for the use of these
topical antibiotics;
.baseline audiometry should be performed, if possible,
before treatment is commenced.
Clinical expertise and judgement should be used to assess
the risk of treatment versus the benefit to the patient in such
circumstances. It is considered that the pus in the middle ear
associated with otitis media also carries a risk of ototoxicity.
Removal of ear wax
Ear wax (cerumen) is a normal bodily secretion which
provides a protectivefilm on the meatal skin and need only
be removed if it causes hearing loss or interferes with a
proper view of the ear drum.
Ear wax causing discomfort or impaired hearing may be
softened using simple remedies such asolive oilear drops or
almond oilear drops; sodium bicarbonate ear drops p. 693
are also effective, but may cause dryness of the ear canal. If
the wax is hard and impacted, the drops can be used twice
daily for several days and this may reduce the need for
mechanical removal of the wax. The child should lie with the
affected ear uppermost for^5 to^10 minutes after a generous
amount of the softening remedy has been introduced into
the ear. Proprietary preparations containing organic solvents
can irritate the meatal skin, and in most cases the simple
remedies indicated above are just as effective and less likely
to cause irritation. Docusate sodium p. 694 or urea hydrogen
peroxide p. 694 are ingredients in a number of proprietary
preparations for softening ear wax.
If necessary, wax may be removed by irrigation with water
(warmed to body temperature). Ear irrigation is generally
best avoided in young children, in children unable to co-
operate with the procedure, in children who have had otitis
media in the last six weeks, in otitis externa, in children with
cleft palate, a history of ear drum perforation, or previous ear
surgery. A child who has hearing in one ear only should not
have that ear irrigated because even a very slight risk of
damage is unacceptable in this situation.Administration
To administer ear drops, lay the child down with the head
turned to one side; for an infant pull the earlobe back and
down, for an older child pull the earlobe back and up.1 Otitis externa
ANTIBACTERIALS›AMINOGLYCOSIDES
Framycetin sulfate
lINDICATIONS AND DOSE
Bacterial infection in otitis externa
▶TO THE EAR
▶Child:(consult product literature)lCONTRA-INDICATIONSPerforated tympanic membrane
lCAUTIONSAvoid prolonged use
lSIDE-EFFECTSLocal reactionlMEDICINAL FORMS
No licensed medicines listed.
Combinations available:Dexamethasone with framycetin
sulfate and gramicidin,p. 670Gentamicin 11-Dec-2017
lINDICATIONS AND DOSE
Bacterial infection in otitis externa
▶TO THE EAR
▶Child:Apply 2 – 3 drops 4 – 5 times a day, (including a
dose at bedtime)lCONTRA-INDICATIONSPatent grommet (although may be
used by specialists, see Ear p. 688 ).perforated tympanic
membrane (although may be used by specialists, see Ear
p. 688 )
lCAUTIONSAvoid prolonged use
lSIDE-EFFECTSDermatitislMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug.
Ear/eye drops solution
EXCIPIENTS:May contain Benzalkonium chloride
▶Gentamicin (Non-proprietary)
Gentamicin (as Gentamicin sulfate) 3 mg per 1 mlGentamicin
0. 3 % ear/eye drops| 10 mlP£ 2. 63 DT = £ 2. 47BNFC 2018 – 2019 Otitis externa 689
Ear, nose and oropharynx12