Ear conditions

• Assessing an ear condition – Gathering Information


  1. Describe the symptoms? E.g. Pain, gradual hearing Loss, discharge, itchiness

  2. Any other symptoms? Dizziness, tinnitus, fever

  3. How long have they been present?

  4. Have you tried any treatments?

  5. Have you had a recent injury? Eg whilst cleaning the ears?

  
• Assessing an ear condition – External Examination


  1. Wash hands

  2. Inspect external ear for redness, swelling or discharge

  3. Check for tenderness in the area behind the pinna (mastoid area)

  4. Check for tenderness in the pinna and tragus

  5. NB The pinna is manipulated differently for adults and children to view the ear canal and instil ear drops. Down for children and up and back for adults.

  
• Common Ear Complaints


  • Impacted wax
  • Otitis externa – Swimmer's Ear
  • Otitis media – Middle Ear Infection
  • Glue Ear
  • Perforation & Trauma

  
• Ear Wax - Impacted


  Wax build up in the ear canal – ear wax is produced by the glands in the skin lining the ear canal (EAM). Ear wax contains less than 50% of fatty matter derived from secretions of the sebaceous ceruminous glands. The majority of the wax consists of desquamated epithelium, foreign matter and shed hairs. This non-fatty material forms a matrix holding together the granules of fatty matter to form the ceruminous mass. It normally naturally moves outwards from the ear drum . ie. the ear is normally self cleaning.

  
• Causes of impacted ear wax


  • Interuption of the natural process by cleaning the ears with ear buds or "other" items
  • Age related decrease in cerumen producing glands causes an increase in drier ear wax in elderly patients

  
• Symptoms of impacted ear wax


  ear ache, blocked ear, ringing in the ears or gradual hearing loss

  
• Ear Wax - Impacted

  Over 30% of ears impacted with wax will clear without intervention in 5 days

  
• Cerumenolytics


  Oil based preparations that aid in softening and dispersing wax by emulsification. Because of their low surface tension and miscibility, rapidly penetrate the dry matrix of the ceruminous mass, reducing the solid matter to a semi-solid debris. This can be ejected by normal physiological processes or in more severe cases syringed away by a medical professional.
• Examples of cerumenolytics


  • docusate (Waxsol)
  • carbamide peroxide (Ear clear)
  • sodium chloride spray (Audiclean)
• Check product indications and appropriate age
• New Cerumol Formulation – Now free of Arachis Oil
• AMH Practice points on ear wax


  • avoid using cotton buds and ear candles
  • over 30% of ears impacted with wax will clear without treatment within 5 days
  • cerumenolytics (including water and saline) and/or syringing may be used to treat impacted ear wax
  • direct comparative trials between interventions are lacking
  • there is no good evidence for appropriate duration of treatment with ear drops alone; a reasonable guide is to use 2–5 drops once or twice daily into the affected ear for 3–5 days
  • gentle syringing with warm (body temperature) water or sodium chloride 0.9% solution may help loosen and remove wax; if wax appears hard and impacted, consider using cerumenolytic drops 15 minutes before syringing
  • avoid syringing if there is a history of otic surgery, perforated eardrum or otitis (externa or media); in particular, people who are deaf in one ear should not have the good ear syringed

  
• Administration of Ear Medications


  1. If possible, the patient should receive help. The ear should be clean and dry (use rolled tissue paper spears) and the patient should lie with the affected ear uppermost.

  2. Ear drops are preferred; warm container in cup of warm water if necessary to reduce viscosity. Instil directly into ear canal then remain in position for 3–5 minutes; gentle massage or pressure on the tragus may aid penetration of the drops.

  3. If the ear canal is too swollen to allow drug entry, drops may be instilled via a clinician-inserted wick or ribbon gauze. This should be reviewed every few days until the swelling subsides; the wick may then fall out on its own accord or be removed.

  4. Ear ointments are used less often as they may accumulate and cause obstruction of the ear canal. A small amount of ointment should be gently squeezed into the ear canal; it may also be used on or around the ear.

  
• CMI Chloromycetin Ear Drops: 'You may warm to body temperature, but no higher, by holding the bottle in your hand for a few minutes. Lie down or tilt your head so the infected ear is facing upwards. Place the required number of drops into the ear canal. Keep the ear facing up for about 5 minutes to allow the medicine to coat the ear canal. For young children who cannot stay still for 5 minutes, try to keep the ear facing up for 1 to 2 minutes. To keep the medicine as germ-free as possible do not touch the dropper to any surface (including the ear). Close the container tightly after use.'

  
• Otitis Externa – Swimmer's Ear


  This is a common generalized inflammation of the EAM. It is usually acute but can be chronic in children, swimmers and water sports or Surfer's ear. Commonly a bacterial or fungal infection of the ear canal.

  
• Causes of Otitis Externa


  Trauma, dermatitis or prolonged exposure of the ear to moisture eg regular swimming in unclean water.
• Symptoms of Otitis Externa


  irritation, itchy ear, pain (made worse by movements…eg: chewing), feeling of pressure or fullness in the ear, discharge (usually clear), mild hearing loss

  
• Treatment of Otitis Externa


  Prescription: Antibacterials, corticosteroids, antifungals can all be used depending on severity.
• Prevention & Pain Management of Otitis Externa

  1. OTC Antiseptic drying agent. Restore acidic pH of external auditory canal and inhibit microbial growth Eg: Acetic acid (Aqua ear) – 4-6 drops in each ear after swimming or bathing

  2. Keep ear dry. During treatment use cotton wool balls smeared in vaseline while showering or bathing

  3. Use ear plugs if swimming.

  4. OTC pain relief for acute pain.

  
• Avoid – Local trauma: eg cleaning ears

  
• When to refer Otitis Externa

  1. OTC treatment is limited. Consider Pain and Duration when deciding whether to refer.

  2. Hearing Impairment

  3. Inflammation of the Pinna

  4. Mucopurulent discharge

  5. Feeling unwell
• Acute Otitis Externa-diffuse - eTG


  • Keep ear canal dry
  • Rx combination corticosteroid and antimicrobial ear drops
  • Ear clean (HCP)
  • Pain management
  • Ear wick if complete occlusion (HCP)
  • Oral antibiotics may be necessary if fever present or special patient group.
  • Keep ear dry for 2 weeks after treatment
  • If symptoms do not improve, return to your doctor.

  
• Otitis Externa – AMH


  • Give all patients adequate pain relief, eg an NSAID. If the pain is severe, consider early referral to an ENT specialist.
  • Keep external ear canal dry by meticulous gentle cleansing and drying with tissue spears (rolled tissue paper). Do this 2–4 times daily if possible (but at least once daily).
• Otitis Media


  Infection of the middle ear cavity is common, especially in children. It is abrupt in onset; symptoms include pain and fever and irritability (in infants); it is caused by viruses and/or bacteria (most commonly Streptococcus pneumoniae, Haemophilus influenzae or Moraxella catarrhalis).

  
• Otitis media


  • Otitis media is inflammation of the middle ear with a build-up of fluid due to a bacterial or viral infection. Otitis media often starts from a common cold.
  • Otitis media causes pain and sometimes fever. There may be a discharge from the ear. Signs include crying, ear-pulling and irritability. Antibiotics may be needed, though not always. This depends on the age of the child, whether there is a fever and the duration of the problem.
  • If symptoms are mild – the analgesic management for the first 1-2 days is recommended and commencement of antibiotics only if there is no symptom improvement.
  • Early antibiotic treatment may hasten recovery and reduce complications

  
• At Risk Patients for Otitis Media


  • Aboriginal and Torres Strait Islander populations:
  • Indigenous children are at greatly increased risk of severe OM
  • Severe or recurrent OM will improve with improved living standards
  • Encourage attendance at local health clinic as soon as possible whenever a child develops ear pain or discharge.
  • Frequent examinations – especially if sick
  • Pharmacists can support Aboriginal and Torres strait islander health staff to have a greater impact on severe OM
• Other at risk patient groups for severe or recurrent Otitis Media


  those with otorrhoea or severe or systemic symptoms, and those with risk factors for serious complications (eg Down syndrome, cleft palate, cochlear implants, the immunocompromised
• Suppurative Otitis Media


  Most severe form of otitis media, characterised by a chronically perforated eardrum and discharge over several weeks (also known as active chronic otitis media). Bacteria present differ from those in acute otitis media and include P. aeruginosa, E. coli, S. aureus, Proteus mirabilis and Klebsiella spp.
• Acute otitis media – eTG


  • Adequate analgesia
  • Antibiotic therapy
  • For most children with acute otitis media, antibiotic therapy can be safely withheld. However, antibiotic therapy is required in the following groups:
  • infants younger than 6 months
  • children younger than 2 years with bilateral acute otitis media or acute otitis media with otorrhea
• Groups requiring treatment for severe or recurrent otitis media


  • Those with otorrhoea or severe or systemic symptoms
  • Those with risk factors for serious complications (eg Down syndrome, cleft palate, cochlear implants, the immunocompromised)
• Suppurative Otitis Media


  Most severe form of otitis media, characterised by a chronically perforated eardrum and discharge over several weeks (also known as active chronic otitis media)
• Bacteria present in suppurative otitis media differ from those in acute otitis media and include P. aeruginosa, E. coli, S. aureus, Proteus mirabilis and Klebsiella spp.
• Indications for antibiotic therapy in acute otitis media

  • Infants younger than 6 months
  • Children younger than 2 years with bilateral infection
  • Children who are systemically unwell (eg lethargic, pale, very irritable); fever alone is not an indication for antibiotic therapy
  • Children with otorrhoea
  • Aboriginal and Torres Strait Islander children—for treatment recommendations, see the Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations
  • Children at high risk of complications (eg immunocompromised children)
• Acute otitis media management


  • Adequate analgesia
  • Antibiotic therapy
  • Symptomatic treatment with analgesics for the first 24–48 hours; start oral antibacterials only if symptoms have not improved (for most mildly unwell patients)
  • Early antibiotic treatment for special patient groups
• Antibiotics of choice for acute otitis media

  Amoxycillin (or cefuroxime if contraindicated)
• Glue ear


  Type of chronic otitis media that mainly affects children, characterised by long-term build-up of thick or sticky fluid in the middle ear, behind the eardrum

  
• Glue ear


  • Hearing impairment often the only symptom
  • Can delay speech development and make socialising and learning difficult
  • Often resolves with no treatment
  • Important that the ear is checked by a doctor to see if treatment is needed, especially if there are speech and/or hearing difficulties
  • Sometimes children will need to have grommets inserted to allow drainage of fluid

  
• Otitis media and glue ear are a health concern in Australian Indigenous children, and continues to be part of the strategy for health, education and closing the gap
• Grommets


  Small tubes surgically inserted into the eardrum to let fresh air into the middle ear, improving hearing by allowing the tiny bones of hearing and eardrum to move freely again

  
• Grommets


  • Usually fall out of the eardrum after 6-12 months and the hole in the eardrum then heals quickly
  • Pharmacist often needs to assist with swimming protection, recommending ear plugs and a swimming cap or ear wrap-type headband