Patient Group Direction for primary treatment of chronic otitis externa

1. Clinical Condition

Patients presenting with a long term repeated ear problem with discomfort and offensive discharge or ear occluded with moist keratin debris. May be excoriation of the skin around meatal entrance. May be signs of seborrhoeic dermatitis. May be severe itching and evidence of fungal infection.

Objective

To identify the cause, clear the present infection and prevent recurrence through patient education, advice and on going support with a speedy ear check should symptoms begin to recur.

Guidelines

Based on ENT text book instructions; ENT consultant advice and BNF.

2. Patients

Inclusion criteria

Patient medical history reveals a repeated problem, the cause for which may be identified in observing scalp and skin condition, or in discussion of daily hygiene (lying in bath water to wash hair). On examination the external meatus will be occluded with discharge and/or keratin debris and any visible meatal skin may be inflamed. Discomfort, hearing loss and odour will be possible patient complaints. If fungal origin, then severe itching is worst complaint.

Exclusion criteria

Any patients who do not meet the inclusion criteria for this patient group, or who may have middle ear disease identified when aural toilet has been performed.

Excluded patients and those refusing treatment

Refer to general practitioner or treat other presenting problems according to the patient group direction for the relevant ear problem.

3. Treatment

Name, Dose, Method and route

Remove discharge and debris from the external auditory meatus by gentle aural toilet or irrigation under direct vision and dry meatus. Dress with a wick (96mm x 12mm wide ribbon gauze) coated with Triamcinolone acetonide 0.1%, Gramicidin 0.25%, Neomycin
sulphate 0.25%, Nystatin 100,000 units ointment for 48 hrs. Return to review dependant on presenting condition and length of history. Neomycin ear spray (Dexamethasone 0.1%, Neomycin sulphate 3250 units/ml, Glacial acetic acid 2%) may be prescribed to continue self care following initial dressing. Research shows spray more effective than similar drops and patient conformity with treatment higher percent.
Self care to be continued no longer than 10 days and review if not improved. Clinical judgement must always be used to meet individual patient need for treatment. If not improving after 48 hrs, take a swab, repeat aural toilet and change to second line treatment - Chlortetracycline Hydrochloride 3%, Triamcinolone acetonide 0.1% ointment) pending swab result. Consider possible combined bacterial and fungal infection and treat accordingly. If fungal spores present thorough aural toilet and treat with Clotrimazole 1%, Hydrocortisone 1% cream dressing for 48 hrs (size as above) necessary to review and repeat treatment for 3 weeks to ensure no spores remain in order to overcome the spore's 3 week life cycle. Clotrimazole 1% ear drops are available for self care if appropriate.

Patient advice

Warn about sensitivities to treatments and possibilities of staining to clothes. Gain informed consent before examination or treatment. Advise about future prevention and the use of Galacial Acetic Acid Spray if initial symptoms recur.

Follow up care

Requires access to repeat treatment until all symptoms have cleared. To return speedily for preventive care should any symptoms recur which are not resolved by use of the spray.

Reporting procedure

Record in patient's notes according to national directions. Contact GP to report any adverse reactions or requirements for secondary advice.

Information recorded

Presenting problem, previous history, present findings, treatment given and any follow up required.

Patient Group Direction for primary treatment of acute otitis externa

1. Clinical Condition

Patients presenting with a sudden onset of (a) weepy, painful, oedematus external meatus or (b) severe localised ear pain around an infected hair follicle (Furuncle)

Objective

To alleviate pain, reduce oedema and prevent exacerbation of the presenting symptoms.

Guidelines

Based on BNF and ENT text book instructions

2. Patients

Inclusion criteria

On examination (a) a weepy, oedematus inflamed and painful external auditory meatus with a patient history of recent bathing in possibly unclean water. Identified through patient description. (b)The patient has severe pain on touching pinna and on examination has a small swelling or a red area near the entrance to the meatus signifying an infected hair follicle. Associated cellulitis or lymph node swelling etc refer to GP.

Exclusion criteria

Any patients who do not meet the inclusion criteria for this patient group.

Excluded patients and those refusing treatment

Refer to general practitioner or treat other presenting problems according to the patient group direction for the relevant ear problem.

3. Treatment

Name, Dose, Method and route

(a) Gentle aural toilet, oral analgesia may be required. Topical glycerine and ichthammol wick for 24 hrs. Coat 96mm of 12mm wide ribbon gauze with medication and gently insert in meatus to soothe and reduce oedema. Review and repeat treatment if necessary or following further aural toilet, change treatment to a wick coated with 1G of Triamcinolone acetonide 0.1%, Gramicidin 0.25%, Neomycin sulphate 0.25%, Nystatin 100,000units, ointment for 48 hrs. To return if no improvement. In this case, take a swab and change to second line management (Chlortetracycline Hydrochloride 3%, Triamcinolone Acetonide 0.1% oint.) (b) Aural toilet is not normally required unless boil has discharged. Repeat topical treatment and oral analgesia as for (a) but a systemic antibiotic will also be required as this is usually a Staph. Aureus skin infection. Suggest Flucloxacillin orally. In all treatments, clinical judgement must be used to provide best practice and individual patient care.

Patient advice

Warn about sensitivities to treatment. Advise about treatment staining clothing, keep ears dry by using cotton wool coated in petroleum jelly when washing hair or showering. Gain informed consent before treatment or examination. Advise about future recognition and prevention by using of galacial acetic acid spray at first signs of (a) recurrence.

Follow up care

Only required if problem deteriorates or returns following previous resolution.

Reporting procedure

Record in patient's notes according to national directions. Contact GP to report any adverse reactions or requirements for secondary advice.

Information recorded

Presenting problem, previous history, findings, treatment given and any follow-up.