Ear Infections

This is the protocol for Ear Infections:

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 (“eardrum”), 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

Otitis media is an infection of the middle ear and it’s 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

Otitis externa is 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.

Image result for moxifloxacin

Image result for z pak


The treatment for otitis externa is slightly different.  This isn’t mentioned in the protocol, but before you proceed with antibiotic treatment, you’ll want to remove any debris or wax buildup from the external auditory canal.  This will help with pain relief, as well as provide a much clearer path for topical antibiotics.  This is a brief video on how to perform an irrigation:

*To help loosen the cerumen, use a warm water mix w/ hydrogen peroxide!

When you’re done, you’ll need to inspect the ear once more to ensure that the debris is cleared and that the tympanic membrane is still intact.  If it’s perforated, the treatment will change! (Oral antibiotics are given instead of topical)

Image result for perforated tm







Once the affected ear canal is mostly clear, you can administer Gatifloxacin, a topical quinolone antibiotic.  Although gatifloxacin is technically only supposed to be used for eye infections, it’s known to be highly effective for ear infections as well.  Using gatifloxacin for both eyes and ears helps reduce the number of drugs you need to keep on hand.  

Image result for gatifloxacin






Naturally, the patient will be in quite some pain.  NSAIDs and Tylenol from the Pain Management protocol will typically suffice.  

Most cases of ear infections are not problematic. With treatment, most patients with otitis externa will improve in 1-3 days and completely resolve within a week. For otitis media, symptoms will improve between 2-3 days, with fluid potentially lingering for up to 3 months.

But if the symptoms aren’t resolving within the treatment time frame, then a Routine evacuation will have to happen in order to prevent more serious issues from occurring, such as mastoiditis, hearing loss, meningitis, etc.

For patient education, be sure to tell your otitis externa patients to avoid swimming for at least 3-4 weeks and to avoid sticking anything in their ears!  We wouldn’t want to have them come back twice.  

Till next time!



Brandon Simpson, PA-C
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