PR2154 otic conditions

Cerumen impaction, water clogged ears, otitis externa, otitis media

How will a patient with cerumen impaction present?

Feeling of pressure or fullness
Ear discomfort
May cause vertigo, tinnitus, puritis
Chronic cough possibile
Can cause **gradual hearing loss**
Pain is often present

What are the information you need to collect for assessment of cerumen impaction?

Course

* duration of symptoms
* onset of symptoms

Associated symptoms:

* Fever
* Pain
* Hearing loss
* Discharge 
* Acute or gradual onset
* Severity
* Dizziness 
* tinnitus

Medical medication history

Urgent need for referal (truama, tinnitus, dizziness)

What are the red flags for referral in all otic conditions

* Signs of infection 
* Pain with discharge
* Recent ear surgery in prior 6 weeks
* Bleeding or signs of trauma 
* Presence of ruptured tympanic membrane or tympanostomy tubes
* Incapable of following proper instructions for use of otic drops 
* Hypersensitivity to recommended agents 
* No improvement after 4 days of self care

What are the goals of therapy for cerumen impaction?

1.  to help alleviate or relieve the symptoms (pain, fullness, hearing loss, tinnitus, etc).
2. Help to **restore normal self-cleansing mechanism of epithelial migration** through pharmacological and non-pharmacological treatments
3. Prevent future cerumen impaction (patient education)

What are the treatment options for cerumen impaction?

Pharmacological (cerumenolytics)

irrigation

manual removal

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What are the cerumenolytic agents available?

Water based

Oil based

Non-oil and non water based

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What are the water based cerumenolytics? MOA

Docusate sodium

* emulsifier, disperse ear wax

Hydrogen peroxide

* release oxygen and mechanically removes debris

What to watch out for water based cerumenolytics?

Allergic reaction -→ rashes, redness

avoid over use

What are the oil based cerumenolytics? MOA

Almond oil

arachis oil

mineral oil

Lubricate and soften cerumen, promote natural removal

what to watch out for oil based cerumenolytics?

Do not use arachis oil in patients with peanut allergies

What are the non- oil based, non-water based cerumenolytics?

Carbamide peroxide

* reacts with the catalase in the tissue to release oxygen
* mild antibacterial effects

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Glycerin

* emollient theraoy and humectant
* soften ear wax, allow natural process to occur

What to watch out for carbamide peroxide?

may produce a crackling sound in the ear that may traumatise the patients

How to properly administer ear drops?

1. Wash hands with soap and warm water; then dry them thoroughly.
2. Carefully wash and dry the outside of the ear with a damp washcloth, taking care not to get water in the ear canal.
3. Warm eardrops to body temperature by holding the container in the palm for a few minutes.
4. Tilt head to the side opposite the affected ear. Or have patient lie on the bed, with the affected ear facing the ceiling. Pull the ear backward and upward to open the ear canal. For a children <3 years old , pull the ear backward and downward.
5. Open the container carefully. Position the dropper tip near, but not inside, the ear canal opening. Do not allow the dropper to touch the ear.
6. Place the proper dose or number of drops into the ear canal. Replace the cap on the container.
7. Keep the head in the same position for a few minutes after instillation.
8. Regain normal position, gently wipe excess medication off the outside of the ear using a clean tissue.
9. Wash your hands to remove any medication.

What are the monitoring parameters for patients with cerumen impaction?

* Evaluate patient response in 2 days 
* Refer if no resolution after 4 days or patient experience symptoms after impaction removal

List a few patient education points for cerumen impaction

What causes water clogged ears?

* It is the retention of water in the external ear canal, causing discomfort and a sense of fullness → gradual hearing loss
* Trapped moisture causes maceration in the external ear canal, compromising natural defenses → more susceptible to infection

What are the red flags that need referral for water clogged ears?

* Signs of infection (fever, pain, discharge etc) 
* Pain associated with ear discharge (otitis media, otitis externa) 
* Recent surgery in ear 6 weeks
* Bleeding or trauma 
* Presence of ruptured tympanic membrane or tympanovstomy tubes 
* Incapable of following proper instructions for use of otic drops
* Hypersensitivity to recommend agents 
* No improvement after 4 days of self care
* Special population: Diabetic patients, immune compromised

What are the goals of therapy for water clogged ears?

1. Relieve symptoms such as muffled hearing, ear fullness by removing the water retention 
2. **Prevent infection** caused by maceration of the external ear cannel
3. Prevent future occurrence through patient education

What are the pharmacological treatment options for water clogged ears?

* Ear drops
* Isopropyl alcohol (95%) → drying effect alcohol with >75% + Glycerin 5% (to balance out the drying effect of glycerin) 

What are the non-pharmacological treatment option for water clogged ears?

* Shower cap, ear plugs
* Tilt affected ear downwards and gently shaking excess water from the water

What are the monitoring parameters for water clogged ears?

* See a doctor if no resolution or new symptoms occur after 4 days of self care

How to educate patients on preventing water clogged ears?

* Prevent water from getting into the ears (ear plugs, shower caps, swimming caps) 
* Dry ears immediately after coming out of the water 

What causes otitis externa?

water enters ear→change pH→ more alkaline→ microflora growth

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* Changes to microflora result from excessive moisture leading to skin maceration and skin cerumen breakdown that changes the microflora of the ear canal → due to pH changes by water entering  (becoming more alkaline)

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local trauma to the ear → bacteria enters

Hearing aid use

Chronic dermatological diseases

What are the most common bacteria that causes otitis externa?

**Pseudomonas aeruginosa,** Staphylococcus spp. and Streptococcus pyogenes

What is the most common fungal infection of otitis externa?

* Aspergillus spp. 

What are some of the Chronic dermatological diseases that can lead to otitis externa?

eczema, psoriasis, seborrheic dermatitis

(present near the ears)

How will a patient with otitis externa present?

* Itching, irritation, erythema
* Acute pain 
* Drainage of foul smelling watery discharge
* Fullness with or without jaw pain 
* Impaired hearing due to occlusion of external auditory canal
* Usually not accompanied by systematic manifestation (differentiate from otitis media)

How do you differentiate between otitis externa and otitis media?

Otitis externa: non-mucopurulent discharge, usually no systemic manifestation

Otitis media: mucopurrulent discharge, systemic manifestation (fever, URTI)

What are the treatment goals for otitis externa?

1. Relieve symptoms
2. Resolve infection (antibiotics etc) 
3. Prevent chronic infection or future infections (antibiotic course, patient education)

What are the pharmacological treatment for otitis externa?

* Topical antimicrobials with acidifying agent (PO drugs) 
* Topical antimicrobial with or without steroids (PO drugs) 
* Painkillers 
* Paracetamol 
* NSAIDs 

what are the patient counselling points on otits externa?

* On the proper use of ear drops or ear sprays 
* Caution patient not to insert anything into the ear
* Avoid water activities for 7-10 days while undergoing treatment
* Ear plugs can be used during showering, bathing or hair washing

How do you check for an adult’ EAM vs a child?

Adult: pull pinna backwards and upwards

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What causes otitis media?

Nasal discharge can reflux into the tympanic tube (bacteria and virus can infect)

usually companied with UTRI

How will a patient with otitis media present?

* Ear popping, ear fullness
* Ear pulling and tugging (children), irritability etc
* Ear pain
* Drainage of mucopurulent discharge (if tympanic membrane is ruptured) 
* Hearing loss (more acute) 
* Dizziness, anorexia
* Systemic 
* Fever
* URT infections