Ear Infection

This is the protocol for Ear Infection:

Ear Infection


Let’s Break it Down!



There are two basic ear infections that you’ll need to be able to identify and treat: Otitis Media (“inflammation of the middle ear”) and Otitis Externa (inflammation of the outer ear).  Before we begin, let’s review some basic ear anatomy:

Image result for inner ear vs outer ear

The outer ear refers to the external canal of the ear….the part you stick your finger into.  The separation between the outer ear and the middle ear is the Tympanic Membrane, which is going to be a key structure to identify during the examination process.  There is also an “inner ear”, which consists of the cochlea, nerves, etc.  However, infections here are very uncommon.

Otitis Media

An infection of the middle ear and by far the most common, affecting about 11% of the global population per year.  Children under the age of 5 make up the majority of cases; their narrow Eustachian tubes make them particularly vulnerable to viruses and bacteria that can become lodged inside the middle ear.  Not particularly common for soldiers, but it should always be checked for if the soldier exhibits signs of an upper respiratory infection, as this is usually what causes these infections.

Otitis Externa

An infection of the external ear; It’s often referred to as “swimmers ear” because bacteria commonly enters the ear canal via water and settles in the now moist environment  Affects about 1-3% of people every year.  For soldiers in dirty environments with nasty fingers, it wouldn’t be hard for them to pick up this infection.

Otitis Media

Patients with Otitis Media will almost always have a history of upper respiratory infection.  During your exam, they may tell you that they have “difficulty hearing” or “pain in my ear”.  These are both due to the increased pressure built up in the middle ear from fluid/pus.  The pressure may be strong enough to cause a noticeable bulging in the tympanic membrane.  This is a picture comparing a normal ear with an ear w/ a bulging TM:

Otitis Externa

The earliest symptom for most patients with otitis externa is a purulent discharge, which occurs in about 60% of patients.  Pain is the next one, which occurs in 70% of patients.  If the patient has been out swimming or been in a warm, moist climate, then you should suspect this w/o even having to look.  The video shows what it’ll look like when you examine the patient’s ear:

And if you don’t remember how to properly examine an ear, check out this video for review:

Although otitis media can technically be caused by both viruses and bacteria, we tend to treat it as a bacterial infection.  It is rather unusual for adults to get an acute case of otitis media, and the complications can be significant, so we tend to err on the side of caution.  With that being said, Moxifloxacin and Azithromycin are both solid choices to help cover the most common causative agents: S. pneumoniae,  nontypeable H. influenzae, and M. catarrhalis.  For what it’s worth, Augmentin is also quite favorable as an antibiotic treatment.

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Brandon Simpson, PA-C
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