Ear clinical skills + workshop

Steps for basic examination of the ear

1. Wash hands

2. Explain procedure

3. Gain patient consent

4. Look for redness, swelling, discharge

5. Press on the tragus [shown in pic] and pull lightly on the pinna

• Pain = suggests otitis externa

• No pain = more likely to be a problem in the middle ear (otitis media)

6. Ask patient to smile » to check for any facial weakness which is one of the 5 cardinal signs of ear disease

Steps for otoscopy

1. Wash hands

2. Introduce yourself

3. Explain procedure

4. Gain patient’s consent 

5. Ask patient which is their better hearing ear

Otoscopy

1. Adopt a stable seated position

2. Choose the largest clean speculum for the patient’s ear canal (in adults, the largest speculum is usually used)

3. Begin by examining the ear least likely to have an abnormality 

4. Switch on light on otoscope

5. When examining the right ear, hold otoscope with the right hand. Extend little finger to rest against the patient’s face so if they move you move with them 

6. With free left hand, pull pinna upwards, outwards and backwards

7. Insert otoscope. Look for:

• Wax

• Discharge

• Inflammation

8. Proceed down the er canal until the tympanic membrane is seen. Move speculum around to examine the whole of the tympanic membrane

9. Gently remove otoscope, continuing to observe the ear canal for any pathology that may have been missed

10. Repeat examination on the other ear

What should you see on a healthy tympanic membrane through the otoscope?

• The handle of the malleus

• The pars tensa

• The pars flaccida

• Cone of light

• Pink and transparent

Common red flags

• Sudden unilateral hearing loss with no other ear pathology » could be acute vascular arterial occlusion

• Unilateral facial weakness associated with ear symptoms » may be due to spread of disease from ear / cranial nerve

• Rare complications of acute otitis media: mastoiditis, meningitis, cerebral abscess

Case Study 1

• It is Friday afternoon and Sam Small has asked the pharmacy assistant if he could speak to the pharmacist as they want to ask their advice about their ear. The pharmacy assistant has referred this request to you, as the community pharmacist.

• You have asked Sam to come to the pharmacy consultation room. You note they are pressing a tissue to their right ear with their right hand.

Otitis media

• Discharge behind tympanic membrane

• Red and inflamed tympanic membrane 

• Perforation of tympanic membrane = don’t use aminoglycosides (ototoxic)

 

Case Study 2

• Three weeks ago David Bolton arranged to see the pharmacist for a Medicines Review as he has been on his hypertension medicines, isosorbide mononitrate, indapamide, nifedipine and Glytrin for many years.

• The pharmacy assistant has asked David to wait to the pharmacy consultation room.

• Elaine, the pharmacy assistant, explains to you that David is anxious to ask you some questions about their ears as they have been having some problems since they returned from their holiday in Spain.

• Review the scenario

• Wax blockage 

• Potentially due to water entering the ear

Treatment: olive oil spray 

Case Study 3

A 3-year-old girl is brought to you with fever and complains that her ear hurts. She developed a cold about 3 days before with sniffles. Her temperature is 37.8°C (100°F). At physical examination, the only abnormalities are slight redness of the throat, a nose full of thick green mucus, and red tympanic membranes.

How would you know if the child has otitis?

• She has ear pain and fever >> local and systemic symptoms

• Red and inflamed tympanic membrane (however cannot show there’s an in ear infection by itself)

• Mucus in nose >> nose and ear connected

• Otitis common in children 3 - 6

Comment on this tympanic membrane

Healthy tympanic membrane

• Can see handle of malleus

• Can see cone of light 

• Translucent 

• No build up of fluid 

Comment on this tympanic membrane

• Red and inflamed 

• Still translucent

• However, not completely infected 

• May be an upper respiratory tract infection e.g. flu/cold

Comment on this tympanic membrane

• Fluid behind tympanic membrane

• No malleus handle

• No cone of light 

• Not translucent 

Comment on this tympanic membrane

Perforation and bulging 

What can and cannot be used if the tympanic membrane is perforated?

Do NOT use:

• Aminoglycoside-containing drops e.g. Neomycin, Gentamicin

• Drops with high alcohol/acid content e.g. Acetic acid 2%, Aluminium acetate or antiseptic ear drops

SAFE to use:

• Fluoroquinolone ear drops (non-ototoxic)

  • Ofloxacin

  • Ciprofloxacin

Otigo ear drops are formulated as an aqueous solution of phenazone 40mg/g and lidocaine (as the hydrochloride) 10mg/g

Draw the structures of the 2 active ingredients. What is the pharmacological mechanism of each active ingredient?

Phenazone:

• Non-opioid analgesic, anti-pyretic and anti-inflammatory drug

• Inhibits the COX-1 and COX-2 enzymes

• Prevents conversion of arachidonic acid to prostaglandins and thromboxanes

• Reduced prostaglandin production = reduced inflammation 

Lidocaine:

• Local anaesthetic

• Blocks voltage-gated Na+ channels

• Prevents conduction of action potentials

• Results in numbness and pain relief 

Otigo ear drops are formulated as an aqueous solution of phenazone 40mg/g and lidocaine (as the hydrochloride) 10mg/g

Suggest why the hydrochloride salt of lidocaine is preferred for the formulation for ear drops. Why is the pH of the formulation important?

• The hydrochloride salt of lidocaine is water-soluble = ensures the drug dissolves readily and produces a stable, uniform solution that can effectively penetrate ear tissues

pH is important because:

• Lidocaine is a basic molecule 

• The pH influences how much lidocaine exists in its un-ionised (lipid-soluble) form, which can penetrate neuronal membranes and effectively block sodium channels

• If the formulation were too acidic, lidocaine would be predominantly ionised, reducing membrane penetration and analgesic effect

What is the composition of Otigo ear drops?

What is the function of each excipient?

Sodium thiosulfate - preservative 

Benzalkonium chloride - preservative 

Ethanol - co-solvent 

Glycerol - co solvent 

Purified water - solvent 

Sodium chloride - ensures it is an isotonic solution 

Sodium hydroxide - adjusts pH

A GP asks you why some drop formulations such as Betnesol® can be applied to the eyes, ears or nose but Otigo cannot. Identify function of each Betnesol® excipient and using your knowledge of formulation science how would you explain this?

• Some drops like Betnesol are formulated as sterile, isotonic, and pH-balanced solutions

• So are safe for use in sensitive areas such as the eyes, ears, and nose.

• In contrast, Otigo is not sterile and contains excipients (e.g., alcohol, glycerol) and pH levels suitable only for the ear canal, not for the delicate ocular or nasal tissues.

• Using Otigo in the eyes or nose could cause severe irritation, pain, or tissue damage.