Acute Otitis Media with Perforation (AOMwiP)

other causes of TM perforation
- barotrauma from
  - explosions
  - scuba diving
  - air travel
- sudden negative pressure
- head trauma
- noise trauma
- insertion of objects into the ear
- iatrogenic from attempting foreign body or cerumen removal.
more commonly a complication of infection from
- acute otitis media
- otitis externa secondary to Aspergillus
Otitis media causes necrosis and ischemia of the TM leading breakdown and rupture. The most common region for rupture is in the central membrane, followed by the anterior central and posterior central regions
AOMwiP and CSOM exist on a continuum of pathology.

Acute otitis media with perforation (AOMwiP) should be diagnosed
- in children with evidence of a recent (< 2 weeks)
- small (< 2% pars tensa) perforation of the tympanic membrane.
Check medical records to make sure AOMwiP has not been diagnosed at least 3 times in 6 months or at least 4 times in 12 months (see recurrent AOM)
Document the duration of ear discharge
Document the size and position of the TM perforation
- This allows the assessment of progression of the disease over time and to guide the use of topical and systemic antibiotics.
- Generally, any readily visible perforation is considered moderate to large

non-pharm:

pharm:

Treat with longer course of antibiotics
- Amoxycillin 50-90mg/kg/day in two to three divided doses for 14 days
- Continue for at least 3 days after ear becomes dry.

Add ear cleaning plus topical ciprofloxacin antibiotics in children with:
- Visible medium to large perforations and/or
- Persistent discharge (despite 7 days oral antibiotics) for more than 2 weeks

Review weekly until the signs of AOM have resolved. Also review within 4 weeks after resolution
for children at high risk of CSOM

Education for AOM with perforation

Show families/caregivers:
- How to clean/dry mop the ears with correctly prepared tissue spears
- How to maximise effects of ear drops by ‘tragal pumping’
Tell the families/caregivers that:
- Their child needs the medications as prescribed to prevent CSOM
- About the likelihood of temporary hearing loss
- It is important to go to the health centre if they have concerns about speach/language development.

tragal pumping

Size and Location of Perforation:
- Large perforations, especially those in the posterosuperior quadrant, are less likely to heal spontaneously and may require surgical intervention.
- Perforations involving the margins of the TM or those that disrupt the annulus may also need specialist evaluation.
- all unsafe perforations:
  - margins of the tympanic membrane, especially in the posterosuperior quadrant.
  - often associated with the formation of a cholesteatoma which can erode and destroy ossicles

Cause of Perforation:
- Perforations due to penetrating trauma or barotrauma (e.g., from explosions, diving) often need specialist assessment.
- Iatrogenic perforations, such as those occurring during medical procedures, should be evaluated by an ENT specialist.
Persistent Symptoms:
- Ongoing symptoms like
  - chronic otorrhea
  - persistent pain
  - hearing loss beyond a typical healing period
  - Vertigo or symptoms suggesting inner ear involvement
Failure to Heal:
- Perforations that do not show signs of healing within a few weeks to months
- Chronic perforations, which are those persisting for several months, often require surgical closure
Complications:
- Any signs of complications such as
  - cholesteatoma
  - mastoiditi
  - significant hearing loss
Underlying Conditions:
- Patients with underlying conditions that may complicate healing, such as diabetes or immunocompromised states, might benefit from an early referral.