E
xt
e
rn
a
l otitis
Hea
lth pro
b
l
e
ms
O
titis
E
t
e
rn
a
is infl
a
mm
a
tion in th
e
out
e
r
ea
r
b
urrow
.
T
his
d
is
ea
s
e
is
a
lot
foun
d
in prim
a
ry h
ea
lth s
e
rvi
ce
s so
d
o
c
tors in s
e
rvi
ce
P
rim
a
ry h
ea
lth must h
a
v
e
th
e ab
ility to
d
i
a
gnos
e a
n
d
Ma
n
a
g
e
m
e
nt
c
ompr
e
h
e
nsiv
e
ly
.
E
xt
e
rn
a
l otitis
c
l
a
ssifi
ca
tion
(
OE
):
1
.
Oe ac
ut
e
a
.
Oe ac
ut
e d
iffus
e
b
r
ea
kf
a
st
.
Oe ac
ut
e c
ir
c
um
ac
tskript
a
,
whi
c
h is
a
h
a
ir folli
c
l
e
inf
ec
tion th
a
t r
a
is
e
s
F
urunk
e
l in th
e
out
e
r
ea
r
b
urrow
.
2
.
Oe c
hroni
c
3
.
OE e
kz
e
m
a
toi
d
,
whi
c
h is
a
m
a
nif
e
st
a
tion of
de
rm
a
tologi
ca
l
ab
norm
a
liti
e
s
,
L
ik
e a
topi
c de
rm
a
titis
,
psori
a
sis
,
or
SLE
.
4
.
Oe Nec
otology
A
n
a
mn
e
sis
(
su
b
j
ec
tiv
e
)
r
e
sults
A c
ompl
a
int
1
.
Pa
in in th
e ea
r
(
O
t
a
lgi
a
),
whi
c
h v
a
ri
e
s from mil
d
to s
e
v
e
r
e
,
e
sp
ec
i
a
lly wh
e
n th
e ea
r l
ea
v
e
s
a
r
e
tou
c
h
ed a
n
d c
h
e
wing
2
.
F
ull t
a
st
e
on th
e ea
r
3
.
Hea
ring
ca
n
be
r
ed
u
ced
4
.
T
h
e
r
e
w
a
s
a b
uzzing soun
d
(
tinnitus
)
5
.
C
ompl
a
ints
a
r
e
usu
a
lly
e
xp
e
ri
e
n
ced
in on
e ea
r
a
n
d
v
e
ry r
a
r
e
ly r
e
g
a
r
d
ing
b
oth
ea
rs
a
t th
e
s
a
m
e
tim
e
6
.
O
th
e
r
c
ompl
a
ints of
c
omor
a
tions th
a
t
ca
n
a
ris
e
:
f
e
v
e
r or f
e
rtil
e
,
ea
rs
w
e
t
R
isk f
ac
tor
1
.
H
istory oft
e
n
ac
tiviti
e
s in w
a
t
e
r
,
for
e
x
a
mpl
e
:
swimming
,
surfing
,
rowing
.
2
.
T
r
a
um
a
history th
a
t pr
ecede
s
c
ompl
a
ints
,
for
e
x
a
mpl
e
:
c
l
ea
ns
e
th
e b
urrow
ea
rs with
ce
rt
a
in tools
,
ins
e
rting
a c
otton
b
u
d
,
ins
e
rt w
a
t
e
r to
I
n th
e ea
r
.
3
.
S
yst
e
mi
c d
is
ea
s
e
history
,
su
c
h
a
s
:
d
i
abe
t
e
s m
e
llitus
,
psori
a
sis
,
de
rm
a
titis
A
topi
c
s
,
SLE
,
HIV
.
S
impl
e
physi
ca
l
a
n
d
supporting r
e
sults
(
o
b
j
ec
tiv
e
)
P
hysi
ca
l
e
x
a
min
a
tion
1
.
Te
n
de
rn
e
ss in
T
r
a
gus
2
.
Ea
r
-
t
e
nsil
e
p
a
in
3
.
O
tos
c
opy
:
a
.
OE Ac
ut
e D
iffus
e
:
L
i
a
ng
Ea
rs
O
ut
d
oor
Na
rrow
,
Lea
th
e
r
Ea
r
Lea
th
e
r
O
utsi
de
H
yp
e
r
e
mis
a
n
d ede
m with un
c
l
ea
r limits
,
a
n
d ca
n
F
oun
d
minimum s
ec
r
e
t s
ec
r
e
t
.
b
r
ea
kf
a
st
.
OE Ac
ut
e S
irkumskript
a
:
F
urunk
e
l on th
e
out
e
r
ea
r
b
urrow
4
.
Ga
rput
a
l
a
t
e
st
:
norm
a
l or
c
on
d
u
c
tiv
e dea
fn
e
ss
S
upport
N
ot n
ece
ss
a
ry
D
i
a
gnosti
c E
nfor
ce
m
e
nt
(
A
ss
e
ssm
e
nt
)
C
lini
ca
l
d
i
a
gnosis
D
i
a
gnosis is
e
nfor
ced ba
s
ed
on
a
n
a
mn
e
sis
a
n
d
physi
ca
l
e
x
a
min
a
tion
.
D
i
a
gnosis of
A
pp
ea
l
Rec
urr
e
nt
,
c
on
d
ritis
,
a
utomotosis p
e
ri
c
on
d
ritis
C
ompli
ca
tions
I
f tr
ea
tm
e
nt is in
ade
qu
a
t
e
,
ab
s
ce
ss
a
ris
e
s
,
c
hroni
c
inf
ec
tions of th
e ea
rs
,
s
ca
rring n
e
twork
,
a
n
d ea
r st
e
nosis
.
C
ompr
e
h
e
nsiv
e Ma
n
a
g
e
m
e
nt
(
P
l
a
n
)
Ma
n
a
g
e
m
e
nt of
1
.
N
on
-
Med
i
c
m
e
ntos
a
:
a
.
C
l
ea
ns
e
th
e ea
rs
ca
r
e
fully with su
c
k
e
rs or
c
otton moist
e
n
ed
with
3
%
H
2
O
2
.
b
r
ea
kf
a
st
.
I
f th
e
r
e a
r
e ab
s
ce
ss
e
s
,
in
c
isions
a
n
d d
r
a
in
a
g
e a
r
e ca
rri
ed
out
.
2
.
Med
i
c
m
e
ntos
a
:
a
.
T
opi
ca
l
•
P
ovi
d
on io
d
in
e a
ntis
e
pti
c
solution
•
OE Ac
ut
e S
irkumskript
a a
t
I
nfiltr
a
t
e S
t
ad
ium
:
ointm
e
nt ikhtiol
,
or
A
nti
b
ioti
c
ointm
e
nt
:
polymixin
-
b
,
ba
sitr
a
sin
.
•
OE Ac
ut
e d
iffus
e
:
t
a
mpon th
a
t h
a
s
bee
n giv
e
n
a
mixtur
e
of polymyxin
-
b
,
Ne
omy
c
in
,
hy
d
ro
c
ortison
e
,
a
n
d
topi
ca
l
a
n
e
sth
e
si
a
.
b
r
ea
kf
a
st
.
S
yst
e
mi
c
•
S
yst
e
mi
c a
nti
b
ioti
c
s
a
r
e
giv
e
n if th
e
inf
ec
tion is quit
e
h
ea
vy
.
•
A
n
a
lg
e
si
c
,
lik
e
p
a
r
ace
t
a
mol or i
b
uprof
e
n
ca
n
be
giv
e
n
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
Pa
ti
e
nts
a
n
d
f
a
mili
e
s n
eed
to
be
giv
e
n
a
n
e
xpl
a
n
a
tion
,
in
c
lu
d
ing
:
1
.
D
on
'
t s
c
r
a
p
e
th
e ea
rs
b
oth with
c
otton
b
u
d
s or oth
e
r tools
2
.
D
uring th
e
tr
ea
tm
e
nt of p
a
ti
e
nts m
a
y not swim
3
.
D
is
ea
s
e ca
n r
e
p
ea
t so you h
a
v
e
to k
ee
p th
e ea
rs insi
de
d
ry
a
n
d
non
-
humi
d c
on
d
itions
Re
f
e
r
e
n
ce c
rit
e
ri
a
1
.
E
xt
e
rn
a
l otitis with
c
ompli
ca
tions
2
.
Ma
lign
a
nt otitis
e
xt
e
rn
a
l
Ac
ut
e
otitis m
ed
i
a
Hea
lth pro
b
l
e
ms
Ac
ut
e
otitis m
ed
i
a
(
OMA
)
is p
a
rti
a
lly infl
a
mm
a
tion or th
e e
ntir
e
mu
c
os
a
mi
dd
l
e ea
rs
,
e
ust
ac
hius tu
be
s
,
m
a
stoi
da
l
a
nthrum
,
a
n
d
m
a
stoi
d ce
lls
h
a
pp
e
ns in l
e
ss th
a
n
3
w
ee
ks
.
A
n
a
mn
e
sis
(
su
b
j
ec
tiv
e
)
r
e
sults
C
ompl
a
ints
(
de
p
e
n
d
ing on th
e OMA
st
a
g
e
th
a
t is
be
ing
e
xp
e
ri
e
n
ced
)
1
.
T
u
ba
l o
cc
lusion st
ad
ium
T
h
e ea
r f
ee
ls full or p
a
in
,
h
ea
ring
ca
n
be
r
ed
u
ced
.
2
.
H
yp
e
r
e
mi
c
st
a
g
e
s
Ea
r p
a
in is g
e
tting int
e
ns
e
,
f
e
v
e
r
,
fussy
a
n
d a
nxi
e
ty
(
on on th
e c
hil
d
/
c
hil
d
),
vomiting
,
loss of
a
pp
e
tit
e
,
c
hil
d
r
e
n usu
a
lly oft
e
n hol
d ea
rs
th
e
p
a
in
.
3
.
S
upur
ac
y
S
t
ad
ium
J
ust lik
e a
hyp
e
r
e
mi
c
st
a
g
e
4
.
Pe
rfor
a
tion
S
t
ad
ium
E
xit s
ec
r
e
tions of th
e ea
rs
5
.
Re
solution
S
t
ad
ium
A
ft
e
r th
e e
xit
,
th
e
int
e
nsity of
c
ompl
a
ints is r
ed
u
ced
(
t
e
mp
e
r
a
tur
e d
own
,
p
a
in
su
b
si
de
,
bab
i
e
s
/
c
hil
d
r
e
n
a
r
e
qui
e
t
e
r
.
I
f
Pe
rforor
a
tion is
,
h
ea
ring
Ca
n r
e
m
a
in r
ed
u
ced
.
R
isk f
ac
tor
1
.
Bab
i
e
s
a
n
d c
hil
d
r
e
n
2
.
Re
p
ea
t
ed
top
a
irw
a
y inf
ec
tions
3
.
S
u
c
ks from th
e b
ottl
e
in
a
lying
d
own position
4
.
C
ong
e
nit
a
l
ab
norm
a
liti
e
s
,
for
e
x
a
mpl
e
:
c
l
e
ft
ce
ilings
,
d
own syn
d
rom
e
,
5
.
Pa
p
a
r
a
n
a
s
a
p rokok
6
.
A
ll
e
rgi
e
s
7
.
L
ow so
c
io
-
ec
onomi
c
l
e
v
e
l
S
impl
e
physi
ca
l
a
n
d
supporting r
e
sults
(
o
b
j
ec
tiv
e
)
P
hysi
ca
l
e
x
a
min
a
tion
1
.
Te
mp
e
r
a
tur
e ca
n in
c
r
ea
s
e
2
.
O
tos
c
opy
3
.
Pe
t
a
l
a
t
e
st
Ca
n
be
foun
d c
on
d
u
c
tiv
e dea
fn
e
ss
,
n
a
m
e
ly
:
R
inn
e
(-)
t
e
st
a
n
d Sc
hw
abac
h t
e
st
short
e
ning of th
e
p
a
inful
ea
r
,
th
e
w
ebe
r t
e
st is l
a
t
e
r
a
liz
ed
to th
e ea
r
si
c
k
.
S
upport
P
ur
e
ton
e a
u
d
iom
e
try
,
if th
e
f
ac
iliti
e
s
a
r
e a
v
a
il
ab
l
e
D
i
a
gnosti
c E
nfor
ce
m
e
nt
(
A
ss
e
ssm
e
nt
)
C
lini
ca
l
d
i
a
gnosis
D
i
a
gnosis is
e
nfor
ced ba
s
ed
on
a
n
a
mn
e
sis
a
n
d
physi
ca
l
e
x
a
min
a
tion
.
D
i
a
gnosis of
A
pp
ea
l
Ac
ut
e
s
e
rous m
ed
i
a
otitis
,
otitis
e
xt
e
rn
a
l
C
ompli
ca
tions
1
.
I
ntr
a
-
t
e
mpor
a
l
c
ompli
ca
tions
:
Lab
irinitis
,
p
a
r
e
sis of f
a
si
a
lis n
e
rvous
,
p
e
tro
ce
tis
,
H
y
d
ro
ce
ph
a
lus otik
2
.
E
xtr
a
-
t
e
mpor
a
l
/
intr
ac
r
a
ni
a
l
c
ompli
ca
tions
:
S
u
b
p
e
riost
ea
l
ab
s
ce
ss
e
s
,
ab
s
ce
ss
e
s
e
pi
d
ur
a
,
p
e
risinous
ab
s
ce
ss
,
su
bd
ur
a ab
s
ce
ss
,
b
r
a
in
ab
s
ce
ss
,
m
e
ningitis
,
La
t
e
r
a
l sinus throm
b
osis
,
ce
r
ebe
ritis
C
ompr
e
h
e
nsiv
e Ma
n
a
g
e
m
e
nt
(
P
l
a
n
)
Ma
n
a
g
e
m
e
nt of
1
.
Med
i
c
m
e
ntos
a
a
.
T
opi
ca
l
I
.
A
t th
e
st
ad
ium of tu
ba
l o
cc
lusion
,
th
e
r
a
py
a
ims to r
e
op
e
n th
e
tu
ba
e
ust
ac
hius
.
T
h
e d
rug giv
e
n is
:
-
G
iv
e
2
%
Te
tr
a
k
a
in
-
HCL e
y
e d
rops
a
s mu
c
h
a
s
1
-
2
d
rops on
E
y
e
s
a
ff
ec
t
ed b
y for
e
ign o
b
j
ec
ts
.
-
U
s
e
th
e
m
a
gnifying gl
a
ss
(
LUP
)
in th
e
r
e
mov
a
l of th
e
o
b
j
ec
t
for
e
ign
.
-
L
ift for
e
ign o
b
j
ec
ts using
c
otton sti
c
ks or
23
g siz
e
syring
e
.
-
T
h
e d
ir
ec
tion of t
a
king for
e
ign o
b
j
ec
ts is
d
on
e
from th
e
mi
dd
l
e
to th
e ed
g
e
.
-
A
pply th
e c
otton li
d
i
a
ffix
ed b
y
P
ovi
d
on io
d
in
e
on
F
or
e
ign pl
ace
.
II
.
A
t th
e Pe
rfor
a
tion
S
t
ad
ium
,
ea
r w
a
shing
d
rugs
a
r
e
giv
e
n
:
-
H
2
O
2 3
%
,
3
tim
e
s
a da
y
,
4
d
rops in th
e ea
rs th
a
t
a
r
e
si
c
k
,
l
e
ft
for
2
-
5
minut
e
s
.
-
Ace
ti
c ace
ti
c
2
%
,
3
tim
e
s
a da
y
,
4
d
rops in th
e
si
c
k
ea
r
.
-
O
flox
ac
in
,
2
tim
e
s
a da
y
,
5
-
10
d
rops in
a
si
c
k
ea
r
,
for
a
m
a
ximum of
2
w
ee
ks
b
r
ea
kf
a
st
.
S
yst
e
mi
c
or
a
l
:
a
nti
b
ioti
c
s
,
a
ntihist
a
min
e
s
(
if th
e
r
e a
r
e
signs of
a
ll
e
rgi
e
s
),
dec
ong
e
st
a
nt
,
a
n
a
lg
e
si
c
/
a
ntipyr
e
ti
c
s
C
ouns
e
ling
a
n
d ed
u
ca
tion
1
.
F
or
bab
i
e
s
/
c
hil
d
r
e
n
,
p
a
r
e
nts
a
r
e
r
ec
omm
e
n
ded
to giv
e
minimum milk
a
t l
ea
st
6
month to
2
y
ea
rs
.
2
.
A
voi
d bab
y
/
c
hil
d
from
e
xposur
e
to
c
ig
a
r
e
tt
e
smok
e
.
P
r
e
v
e
ntion
HIB a
n
d PCV
immuniz
a
tion n
eed
to
be c
ompl
e
t
ed
,
acc
or
d
ing to th
e
immuniz
a
tion
s
c
h
ed
ul
e
gui
de
2014
c
hil
d
r
e
n from
Ida
i
.
Re
f
e
r
e
n
ce c
rit
e
ri
a
1
.
I
f th
e
r
e
is
a
n in
d
i
ca
tion of tiltingotomy
.
2
.
I
f th
e
r
e
is
c
ompli
ca
tions from
ac
ut
e
otitis m
ed
i
a
.
E
quipm
e
nt
1
.
h
ead
lights
2
.
Ea
r funn
e
l
3
.
O
tos
c
op
e
4
.
C
otton
a
ppli
ca
tor
5
.
Ga
rput
a
l
a
6
.
S
u
c
tion
O
titis
c
hroni
c
suppur
a
tiv
e
m
ed
i
a
Hea
lth pro
b
l
e
ms
Na
tion
a
l
S
urv
e
y of
Hea
lth
I
n
d
r
a S
ight
a
n
d Hea
ring
(
1993
-
1996
)
I
n
8
I
n
d
on
e
si
a
n provin
ce
s show
ed a
n
ENT
mor
b
i
d
ity of
38
.
6
%
.
O
titis
c
hroni
c
suppur
a
tiv
e
m
ed
i
a
is th
e
m
a
in
ca
us
e
of
d
isor
de
r
h
ea
ring o
b
t
a
in
ed
in
c
hil
d
r
e
n
e
sp
ec
i
a
lly in th
e c
ountry
de
v
e
lop
.
I
n
1990
,
a
roun
d
28
,
000
Keca
t
a
n
d
i
W
orl
d
wi
de
ca
us
ed b
y
c
ompli
ca
tions of otitis m
ed
i
a
.
O
titis
c
hroni
c
supur
a
tiv
e
m
ed
i
a
(
OMSK
)
is th
e c
hroni
c
infl
a
mm
a
tion of th
e
mi
dd
l
e
ea
r
with
a
tymp
a
ni
c
m
e
m
b
r
a
n
e
p
e
rfor
a
tion
a
n
d a
s
ec
r
e
t history of th
e
s
ec
r
e
t of th
e ea
r
M
or
e
th
a
n
2
months
,
b
oth
c
ontinuously
a
n
d
lost
.
T
h
e
r
e a
r
e
two typ
e
s
O
msk
,
n
a
m
e
ly
O
msk typ
e
s
a
f
e
(
without
c
hol
e
st
ea
tom
a
)
a
n
d
th
e
typ
e
of
da
ng
e
r
(
with
kol
e
st
ea
tom
a
).
A
n
a
mn
e
sis
(
su
b
j
ec
tiv
e
)
r
e
sults
A c
ompl
a
int
1
.
E
xit th
e
liqui
d
from th
e ea
rs
c
ontinuously or
d
is
a
pp
ea
r
ed
mor
e
th
a
n
2
months
2
.
H
istory
e
v
e
r g
e
t out of th
e
flui
d
from th
e ea
rs of th
e ea
r
be
for
e
.
3
.
F
lui
d ca
n
be
y
e
llow
/
y
e
llow
-
gr
ee
nish
/
mix
ed b
loo
d
/
C
l
ea
r
/
sm
e
ll
4
.
Hea
ring loss
R
isk f
ac
tor
Le
ss hygi
e
n
e a
n
d
m
a
lnutrition
,
r
ec
urr
e
nt top
a
irw
a
y inf
ec
tions
,
pow
e
r
H
ol
d a
low
b
o
d
y
,
a
n
d d
iv
e
rs
.
S
impl
e
physi
ca
l
a
n
d
supporting r
e
sults
(
o
b
j
ec
tiv
e
)
P
hysi
ca
l
e
x
a
min
a
tion
O
toskopi
:
1
.
OMSK Sa
f
e T
yp
e
(
T
u
b
otimping
a
n
)
Pe
rfor
a
tion in th
e ce
ntr
a
l or p
a
rs t
e
ns
a
in th
e
form of ki
d
n
e
y or roun
d
Sec
r
e
t
a
ry is usu
a
lly mu
c
oi
d a
n
d
not too sm
e
lly
M
u
c
os
a Ca
vum
Ta
mp
a
i looks
ede
m
a
,
hyp
e
rtrophy
,
gr
a
nul
a
tion
,
or
timp
a
noskl
e
rosis
2
.
O
msk
Da
ng
e
r
T
yp
e
Pe
rfor
a
tion
A
tik
,
m
a
rgin
a
l
,
or l
a
rg
e ce
nt
a
l
(
tot
a
l
)
Sec
r
e
t
a
ry is v
e
ry sm
e
lling
,
y
e
llow gr
a
y
,
purul
e
nt
,
a
n
d ca
n
look shiny whit
e
pi
ece
s
C
hol
e
st
ea
tom
a
S
upport
1
.
Ga
rput
a
l
a R
inn
e
t
e
st
,
Webe
r
,
Sc
hw
abac
h shows th
e
kin
d
of
dea
fn
e
ss
p
a
ti
e
nt
e
xp
e
ri
e
n
ced
2
.
P
ur
e
ton
e a
u
d
iom
e
try
3
.
Ma
st
T
oi
d
photo
(
if
a
v
a
il
ab
l
e
)
A
tt
ac
hm
e
nt
D
i
a
gnosis
(
A
ss
e
ssm
e
nt
)
C
lini
ca
l
d
i
a
gnosis
D
i
a
gnosis is
e
nfor
ced ba
s
ed
on
a
n
a
mn
e
sis
a
n
d
physi
ca
l
e
x
a
min
a
tion
.
C
ompli
ca
tions
1
.
I
ntr
a
t
e
mpor
a
l
c
ompli
ca
tions
:
Lab
yrinitis
,
p
a
r
e
sis of f
a
si
a
lis n
e
rv
e
s
,
hy
d
ro
ce
ph
a
lus
otik
,
p
e
tro
c
itis
2
.
I
ntr
ac
r
a
ni
a
l
c
ompli
ca
tions
ab
s
ce
ss
(
su
b
p
e
riosth
ea
l
,
e
pi
d
ur
a
l
,
p
e
risinus
,
su
bd
ur
a
,
b
r
a
in
),
l
a
tryn
a
l sinus throm
b
osis
,
s
e
r
ebe
rnitis
C
ompr
e
h
e
nsiv
e Ma
n
a
g
e
m
e
nt
(
P
l
a
n
)
1
.
N
on
-
m
ed
i
ca
l
a
m
e
ntos
C
l
ea
n
a
n
d d
ry th
e ea
r
ca
n
a
l with
c
otton sti
c
k or
C
otton
B
u
d
.
Ea
r w
a
shing
d
rugs
ca
n
be
0
.
9
%
NaC
l
,
2
%
ace
ti
c ac
i
d
,
or hy
d
rog
e
n p
e
roxi
de
3
%
.
2
.
Med
i
c
m
e
ntos
a
a
.
T
opi
ca
l
a
nti
b
ioti
c
s of th
e
group oflox
ac
in
,
2
x
4
d
rops p
e
r
da
y in th
e ea
r
si
c
k
b
r
ea
kf
a
st
.
O
r
a
l
a
nti
b
ioti
c
s
:
•
Ad
ults
:
-
F
irst
L
in
e
:
A
moxi
c
illin
3
x
500
mg p
e
r h
a
ris
e
l
a
m
a
7
da
ys
,
or
X
oxi
c
illin
-
C
l
a
vul
a
n
a
t
Ac
i
d
3
x
500
mg p
e
r
da
y for
7
Da
y
,
or
2
x
500
mg for
7
da
ys
.
-
Sec
on
d
lin
e
:
Le
voflox
ac
in
1
x
500
mg p
e
r
da
y for
7
Da
y
,
or
CeFad
roxil
2
x
500
-
100
mg p
e
r
da
y for
7
da
ys
.
•
C
hil
d
:
-
A
moxi
c
illin
-
C
l
a
vul
a
n
a
t
e Ac
i
d
25
-
50
mg
/
kg
BB
/
da
y
,
d
ivi
ded
be
3
d
os
e
s p
e
r
da
y
,
or
-
Ce
f
ad
roxil
25
-
50
mg
/
kg
BB
/
da
y
,
d
ivi
ded
into
2
d
os
e
s p
e
r
th
e da
y
.
F
ollow up pl
a
n
T
h
e
r
e
spons
e
to th
e
r
a
py w
a
s
e
v
a
lu
a
t
ed a
ft
e
r tr
ea
tm
e
nt for
7
da
ys
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
1
.
Ma
int
a
in th
e c
l
ea
nlin
e
ss of th
e ea
r
a
n
d d
o not s
c
r
a
p
e
th
e ea
r with
S
h
a
rp it
e
ms
.
2
.
Kee
p th
e ea
rs not
c
on
ced
ing w
a
t
e
r
.
3
.
e
xpl
a
in th
a
t this
d
is
ea
s
e
is
a
n inf
ec
tious
d
is
ea
s
e
so
with prop
e
r h
a
n
d
ling it
ca
n
be c
ur
ed b
ut if l
e
ft
Ca
n l
ead
to loss of h
ea
ring
a
n
d
oth
e
r
c
ompli
ca
tions
.
Re
f
e
r
e
n
ce c
rit
e
ri
a
1
.
Da
ng
e
r typ
e OMSK
2
.
T
h
e
r
e a
r
e
no improv
e
m
e
nts to th
e
r
a
py
ca
rri
ed
out
3
.
T
h
e
r
e a
r
e e
xtr
ac
r
a
ni
a
l
a
n
d
intr
ac
r
a
ni
a
l
c
ompli
ca
tions
4
.
Pe
rfor
a
tions s
e
ttl
ed a
ft
e
r
2
months of
d
ry
ea
rs
E
quipm
e
nt
1
.
h
ead
lights
2
.
Ea
r sp
ec
ulum
3
.
O
tos
c
op
e
4
.
C
otton
a
ppli
ca
tor
5
.
C
otton
6
.
Ea
r irrig
a
tion liqui
d
7
.
S
u
c
tion
8
.
K
i
d
n
e
y
c
ont
a
in
e
r
(
N
i
e
r
be
kk
e
n
)
9
.
Ea
r
I
rig
a
tor
(
S
puit
20
-
50
CC
+
Ca
t
e
t
e
r
W
ing
Need
l
e
)
10
.
Ga
rput
a
l
a F
r
e
qu
e
n
c
y
512
-
1024
H
z
F
or
e
ign o
b
j
ec
t in th
e ea
r
Hea
lth pro
b
l
e
ms
T
h
e e
xt
e
rn
a
l
ac
oustikus
(
Mae
)
m
ea
tus is on
e
p
a
rt of th
e b
o
d
y
F
r
e
qu
e
ntly
e
nt
e
r
ed b
y for
e
ign o
b
j
ec
ts
,
whi
c
h
ca
n
be
:
1
.
Reac
tiv
e
for
e
ign o
b
j
ec
t
,
for
e
x
a
mpl
e
:
ba
tt
e
ry
,
iron pi
ece
s
.
Reac
tiv
e
for
e
ign o
b
j
ec
t
da
ng
e
rous
beca
us
e
it
ca
n r
eac
t with th
e Mae e
pith
e
lium
a
n
d ca
us
e
Ede
m
a a
n
d
o
b
stru
c
tion to
ca
us
e
s
ec
on
da
ry inf
ec
tions
.
E
xtr
ac
tion
must
be d
on
e
imm
ed
i
a
t
e
ly
.
2
.
N
on
-
r
eac
tiv
e
for
e
ign o
b
j
ec
t
(
in
e
rt
).
T
his for
e
ign o
b
j
ec
t
d
o
e
s not r
eac
t with
e
pith
e
lium
a
n
d
r
e
m
a
in in
Mae
without
ca
using symptoms until
I
nf
ec
tion o
cc
urr
ed
.
3
.
F
or
e
ign o
b
j
ec
t ins
ec
ts
,
whi
c
h
ca
n
ca
us
e
irrit
a
tion
a
n
d
p
a
in
d
u
e
mov
e
m
e
nt
.
A
n
a
mn
e
sis
(
su
b
j
ec
tiv
e
)
r
e
sults
A c
ompl
a
int
1
.
H
istory is
c
l
ea
rly for
e
ign o
b
j
ec
t
e
nt
e
ring th
e ea
r int
e
ntion
a
lly or not
2
.
T
h
e ea
rs
a
r
e c
logg
ed
or full
3
.
Ea
rs
b
uzzing
4
.
Pa
in in th
e ea
r
5
.
E
xit th
e
flui
d
of th
e ea
r th
a
t
ca
n sm
e
ll
6
.
Hea
ring loss
R
isk f
ac
tor
1
.
C
hil
d
r
e
n
2
.
Me
nt
a
l r
e
t
a
r
da
tion
S
impl
e
physi
ca
l
a
n
d
supporting r
e
sults
(
o
b
j
ec
tiv
e
)
P
hysi
ca
l
e
x
a
min
a
tion
Mae e
x
a
min
a
tion with
a
fl
a
shlight
/
h
ead
light
/
otos
c
op
e
shows
th
e
r
e a
r
e
for
e
ign o
b
j
ec
ts
,
ede
m
a a
n
d
hyp
e
r
e
mi
a
out
e
r
ea
rs
,
a
n
d ca
n
acc
omp
a
ni
ed b
y s
ec
r
e
tions
.
A
tt
ac
hm
e
nt
D
i
a
gnosis
(
A
ss
e
ssm
e
nt
)
C
lini
ca
l
d
i
a
gnosis
C
lini
ca
l
d
i
a
gnosis is
e
nfor
ced ba
s
ed
on
a
n
a
mn
e
sis
a
n
d
physi
ca
l
e
x
a
min
a
tion
.
C
ompli
ca
tions
T
ymp
a
ni
c
m
e
m
b
r
a
n
e
ruptur
e
,
ea
r
b
l
eed
ing
,
e
xt
e
rn
a
l otitis
,
dea
f
c
on
d
u
c
tiv
e
C
ompr
e
h
e
nsiv
e Ma
n
a
g
e
m
e
nt
(
P
l
a
n
)
1
.
N
on
-
Med
i
c
m
e
ntos
a
:
E
xtr
ac
tion of for
e
ign o
b
j
ec
ts
a
.
I
n th
e ca
s
e
of n
e
w for
e
ign o
b
j
ec
ts
,
e
xtr
ac
tion is
d
on
e
in
L
o
ca
l
a
n
e
sth
e
si
a
.
b
r
ea
kf
a
st
.
I
n th
e ca
s
e
of str
a
ng
e
for
e
ign o
b
j
ec
ts
,
th
e
gr
a
nting of liqui
d
s is
a
voi
ded
beca
us
e
ca
n
ca
us
e c
orrosion
.
C
..
I
n th
e ca
s
e
of for
e
ign o
b
j
ec
ts in th
e
form of ins
ec
ts
:
Wa
rf
a
ll
e
ry of
a
l
c
ohol
,
lo
ca
l
a
n
e
sth
e
ti
c d
rug
(
L
i
d
o
ca
in
e S
pr
a
y
or
d
rops
),
or min
e
r
a
l oil for
±
10
minut
e
s for
Ma
k
e
ins
ec
ts not mov
e a
n
d
m
e
li
b
ri
ca
t
e Mae
'
s w
a
lls
.
A
ft
e
r th
e
ins
ec
t is
dead
,
ins
ec
ts
a
r
e
h
e
l
d a
n
d
r
e
l
ea
s
ed
with for
ce
ps
a
lig
a
tor or irrig
a
tion using w
a
t
e
r
acc
or
d
ing to th
e
t
e
mp
e
r
a
tur
e
th
e b
o
d
y
.
2
.
Med
i
c
m
e
ntos
a
a
.
A
nti
b
ioti
c ea
r
d
rops
a
r
e
only giv
e
n if it h
a
s
bee
n
c
onfirm
ed
th
e
r
e
is no
T
ymp
a
ni
c
m
e
m
b
r
a
n
e
ruptur
e
.
b
r
ea
kf
a
st
.
A
n
a
lg
e
si
c
to r
ed
u
ce
p
a
in
C
ouns
e
ling
a
n
d ed
u
ca
tion
Pa
r
e
nts
a
r
e ad
vis
ed
to k
ee
p th
e c
hil
d
'
s
e
nvironm
e
nt from o
b
j
ec
ts
pot
e
nti
a
lly put into th
e ea
r or nos
e
.
Re
f
e
r
e
n
ce c
rit
e
ri
a
I
f for
e
ign o
b
j
ec
ts
a
r
e
not su
cce
ssfully issu
ed
.
E
quipm
e
nt
1
.
h
ead
lights
2
.
O
tos
c
op
e
3
.
Se
rum
e
n hooks
4
.
C
otton
a
ppli
ca
tor
5
.
F
or
ce
ps
A
lig
a
tor
6
.
20
cc
spuit th
a
t h
a
s
bee
n
c
onn
ec
t
ed
with
a
wing n
eed
l
e
hos
e
7
.
S
u
c
tion
P
rop
Hea
lth pro
b
l
e
ms
Se
rum
e
n is
a
s
ebace
ous
ce
r
e
mony
,
s
e
ruminous gl
a
n
d
,
l
ea
th
e
r
e
pith
e
lium
De
spit
e
,
a
n
d d
ust p
a
rti
c
l
e
s
c
ont
a
in
ed
in th
e ca
rtil
a
ginous hol
e
ea
r
.
I
f this s
e
rum
e
nt is
e
x
ce
ssiv
e
,
it
ca
n form
a b
lo
b
S
t
ac
king in th
e ea
rs of th
e ea
rs
,
known
a
s prop
.
A
n
a
mn
e
sis
(
su
b
j
ec
tiv
e
)
r
e
sults
A c
ompl
a
int
1
.
F
ull t
a
st
e
on th
e ea
r
2
.
Red
u
ced
h
ea
ring
3
.
Pa
in in th
e ea
r
4
.
C
ompl
a
ints
a
r
e
in
c
r
ea
singly
e
xp
e
rti
b
l
e
if th
e ea
rs
a
r
e c
on
ceded
(
whil
e ba
thing
or swim
)
5
.
S
om
e
p
a
ti
e
nts
a
lso
c
ompl
a
in
ab
out v
e
rtigo or tinnitus
R
isk f
ac
tor
1
.
C
hroni
c
l
e de
rm
a
titis out
e
r
ea
rs
2
.
Na
rrow
ea
rflow
3
.
Ma
ny
a
n
d d
ry pro
d
u
c
tion pro
d
u
c
tion
4
.
Ea
r
-
c
rown h
ab
its
S
impl
e
physi
ca
l
a
n
d
supporting r
e
sults
(
o
b
j
ec
tiv
e
)
P
hysi
ca
l
e
x
a
min
a
tion
1
.
O
tos
c
opy
:
O
ut
e
r
ea
r hol
e
o
b
stru
c
tion
b
y y
e
llow m
a
t
e
ri
a
l
B
rownish or
b
l
ac
kish
.
T
h
e c
onsist
e
n
c
y of th
e
s
e
rum
e
nt
ca
n v
a
ry
.
2
.
Pe
t
a
l
a
t
e
st
:
norm
a
l or
c
on
d
u
c
tiv
e dea
fn
e
ss
S
upport
N
o
S
upporting
C
h
ec
kup
D
i
a
gnosti
c E
nfor
ce
m
e
nt
(
A
ss
e
ssm
e
nt
)
C
lini
ca
l
d
i
a
gnosis
D
i
a
gnosis is
e
nfor
ced ba
s
ed
on
a
n
a
mn
e
sis
a
n
d
physi
ca
l
e
x
a
min
a
tion
.
D
i
a
gnosis of
A
pp
ea
l
F
or
e
ign o
b
j
ec
ts in th
e
hol
e
.
C
ompli
ca
tions
1
.
E
t
e
rn
a
l otitis
2
.
T
r
a
um
a
on th
e ea
rs of th
e ea
rs
a
n
d
or m
e
m
b
r
a
n
e
s of
T
imp
a
ni wh
e
n issuing
s
e
rum
e
n
C
ompr
e
h
e
nsiv
e Ma
n
a
g
e
m
e
nt
(
P
l
a
n
)
Ma
n
a
g
e
m
e
nt of
1
.
N
on
-
Med
i
c
m
e
ntos
a
:
Se
rum
e
n
E
v
ac
u
a
tion
a
.
W
h
e
n
a
soft s
e
rum
e
nt
,
c
l
ea
n
ed
with
c
otton wr
a
pp
ed a
roun
d
c
otton pillow
.
b
r
ea
kf
a
st
.
W
h
e
n
a
s
e
r
e
num is h
a
r
d
,
it is issu
ed
with
a
hook or
c
ur
e
tt
e
.
I
f th
e
I
n this w
a
y th
e
s
e
rum
e
nt
ca
nnot
be
r
e
mov
ed
,
th
e
n th
e
s
e
rum
e
nt
must
be
soft
e
n
ed
first with
10
%
ca
roglis
e
rin
d
rops or
H
2
O
2 3
%
for
3
da
ys
.
C
..
T
h
e
s
e
rum
e
nt th
a
t is too f
a
r is push
ed
into th
e ea
rs of th
e ea
rs
so it is f
ea
r
ed
to
ca
us
e
tr
a
um
a
to th
e
tymp
a
ni
c
m
e
m
b
r
a
n
e
W
h
e
n r
e
moving it
,
it is issu
ed b
y
d
riving
(
irrig
a
tion
)
Wa
rm w
a
t
e
r whos
e
t
e
mp
e
r
a
tur
e
is
ad
just
ed
to
b
o
d
y t
e
mp
e
r
a
tur
e
.
2
.
Med
i
c
m
e
ntos
a
Ca
roglis
e
rin
ea
r
d
rops
10
%
or
3
%
H
2
O
2
for
3
da
ys for
S
oft
e
n th
e
s
e
rum
e
nt
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
1
.
E
n
c
our
a
g
e
p
a
ti
e
nts not to
c
l
ea
n th
e ea
rs
e
x
ce
ssiv
e
ly
,
B
oth with
c
otton
b
u
d
s or oth
e
r tools
.
2
.
E
n
c
our
a
g
e
p
a
ti
e
nts to
a
voi
d
ins
e
rting w
a
t
e
r or
a
nything to
in th
e ea
r
Re
f
e
r
e
n
ce c
rit
e
ri
a
:
I
f
c
ompli
ca
tions o
cc
ur
d
u
e
to s
e
rum
e
nt
e
xp
e
n
d
itur
e ac
tions
.
E
quipm
e
nt
1
.
h
ead
lights
2
.
Ea
r sp
ec
ulum
3
.
O
tos
c
op
e
4
.
H
ook
Se
rum
e
n
(
Se
rum
e
n
H
ook
)
5
.
C
otton
a
ppli
ca
tor
6
.
C
otton
7
.
Ea
r irrig
a
tion liqui
d
8
.
F
ors
e
p
A
lig
a
tor
9
.
S
u
c
tion
10
.
Ba
yon
e
t tw
ee
z
e
rs
11
.
K
i
d
n
e
y
c
ont
a
in
e
r
(
N
i
e
r
be
kk
e
n
)
12
.
Ea
r
I
rig
a
tor
(
S
puit
20
-
50
CC
+
Ca
t
e
t
e
r
W
ing
Need
l
e
)
13
.
A
l
c
ohol
70
%
