History and Examination

• History of grommet implantation/ previous surgery
• Known chronic ear disease +/- perforation
• Acute suppurative otitis media

Signs and Symptoms

• Discharge
• Hearing loss
• Pain
• Temperature
• Mastoid swelling or tenderness
• Imbalance or nystagmus
• Cranial nerve involvement or evidence of intracranial pathology (e.g. delirium)
• There may be concurrent development of otitis externa

Differential Diagnoses

• Otitis media
• Otitis externa

• Severe pain/ cellulitis
• Suspected intra-cranial sepsis
• Facial nerve palsy
• Vertigo
• Suspicion of acute mastoiditis

If red flags present refer to on call ENT

Acute suppurative otitis media with perforation (severe pain and temperature followed by discharge and improvement in pain level.)

• Adults antibiotics/ analgesia - Joint Formulary chapter 12
• Children who are otherwise well consider deferred antibiotics
• Keep ears dry. Protect ears in bath or shower from soap, shampoo and water. No swimming until review.
• Review in primary care at 6 weeks to check ear drum is normal
• Consider topical quinolone drops if persistent discharge with no other symptoms
• Continuing discharge or abnormal ear drum at 6 weeks refer to ENT

Chronic suppurative otitis media (chronic tympanic membrane or middle ear disease)

• Treat according to Joint Formulary chapter 12
• Prescribe topical antibiotics and steroid drops and pain killers
• Give general advice
  • do not poke ears, attempt to clean ear canals with implements like cottonbuds, and keep protected from shampoo, soap and water. Cotton wool and Vaseline earplugs can beeffective protection.
• If symptoms are unresolved:
  • refer to ENT - see considerations referral

Adults and children with grommets
Discharging ear in a well patient with grommets

• topical ciprofloxacin eye drops (unlicensed) used in the ear.
• Keep ears dry. Do not attempt to clean ear canals

Formulary Chapter 12.1 Ear

Referral Criteria

• Any red flags present
• Persistent discharge despite treatment

All referrals to include:

• Patient history
• Treatments already tried, duration tried, side effects, response

Referral Instructions

Referral for adults

e-Referral Service Selection

• Specialty: ENT
• Clinic Type: Ear
• Service: DRSS-Eastern-Ear Nose and Throat-Devon ICB- 15N

Referral for children

e-Referral selection

• Speciality: Children's & Adolescent Services
• Clinic type: ENT
• Service: DRSS-Eastern-Child & Adolescent Services-Devon ICB - 15N

Referral Form

DRSS Referral Form

Patient Information

Otitis media patient information leaflet

Glue ear

Water precautions for ears leaflet - NDHT

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: July 2017

Reviewed: April 2024