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Improving care standards for external ear problems

Rosemary W Rodgers
MA(Ed) PGDipEd RGN RSCN
Consultant
specialist nurse (ear care)
Rosemary Rodgers Ear Care Services
Rotherham
South Yorkshire

In Rotherham we have led the field in the prevention of ear problems for the past 12 years. Here I present  the methods and the accompanying evidence we use.

Prescribing habits die hard
Many medical staff prescribe oral antibiotics for otitis externa, but evidence shows these are usually ineffective because the fibrosis of the external auditory meatus prevents adequate concentrations of the antibiotic reaching the site of disease.(1)
 
Oral antibiotics are appropriate in the treatment of otitis externa only if there is accompanying cellulitis, lymphadenitis or mastoiditis.(2) Disease persistence and recurrence rates are higher in patients prescribed oral antibiotics.(3) Topical treatment is more effective than systemic antibiotics.(4)
 
The predominant organism associated with this condition is Pseudomonas aeruginosa, which was cultured from 50-65% of affected ears in one study.(2) The systemic antibiotics frequently prescribed may not be active against P. aeruginosa.

Another way in which prescribing costs can be reduced is by considering cerumenolytics. In the removal of ear wax instructions in the British National Formulary, most of the commonly prescribed and over-the-counter drops are marked as preferable not to prescribe.(5)
 
The main purpose of cerumenolytics is to soften and lubricate wax ready for removal without having any adverse effects on the skin-lined cul-de-sac. Nurses frequently report seeing inflamed skin in ears that have been treated with drops containing organic solvents, which the BNF states "can cause skin irritations".(5) This fact is also confirmed in an independent study.(6)

Contraindications to the use of these cerumenolytics include perforated tympanic membrane, previous otitis externa and other skin disorders, including seborrhoeic dermatitis. It is usually impossible to identify a perforation or potential otitis externa behind a wax-occluded auditory meatus. For this reason we have found olive oil less likely to cause discomfort or skin problems, and it is very effective in the lubrication of the wax, enabling easy removal. Lubricating the skin with oil is, in most cases, beneficial.(7) People with dry flaky skin or previous otitis externa have found that sodium bicarbonate drops, although very effective in breaking up wax, cause drying, cracking and irritation of the skin.

Confident ear care

Otoscopy
Confidence begins by being able to translate what is viewed through an otoscope. Visualisation is made easier by using an otoscope with a white halogen, fibreoptic light. Holding the otoscope as you would a pencil and using your small finger to steady your hand enables safety in examination. If the meatus is clear of debris, the normal features of the tympanic membrane and middle ear can be recognised.(8). An external ear canal obstructed by keratin debris is correctly translated as a possible ear infection. It should not be dismissed as crumbly wax.

Syringing
In order to observe the whole procedure it is advisable for the clinician to sit at the same level as the patient and wear a headlight. The stream of water is aimed correctly at the superior aspect of the posterior meatal wall, just at the entrance to the external ear canal. This allows the wax to be lifted clear sooner, minimising the possibility of complications and litigation.(9,10)
 
Deciding whether to syringe or to lift out the wax is based on clinical judgement and patient consent, and on the frequency of meatal occlusions, the amount of wax present, the ability of the clinician and the condition of the ear canal skin. After syringing it is beneficial to dry the whole ear canal and prevent potential problems developing, as static water can lead to bacterial infection. Finally, examine the meatus and treat any inflamed areas.

Know ear wax
Understanding the composition of presenting cerumen may enable prevention of future buildup.(11) Elderly people have drier wax and decreased mobility in the ear canal and are thus more likely to have wax blockage.(11,12) Cerumen is the cause of 80% of all hearing aid repairs.(12)

Common external ear problems in general practice and their prevention
Itchy ears, inflamed or traumatised skin, minor otitis externa or inflammation following removal of hard wax, chronic otitis externa, acute otitis externa and middle-ear disease can all be seen regularly in general practice. Patient Group Directives prepared to cover each of these common ear problems and followed by all members of the primary care team will speedily eliminate major ear problems.

At the Stag Medical Centre we rarely encouary care team will speedily eliminate major ear problems. nter major ear problems or have to prescribe ear drops or syringe. The majority of our patients have been educated about preventing their problems and now attend six monthly for preventive ear checks, which take less than five minutes, as opposed to previously when "as and when" syringing and doctors' appointments were provided, which could take 15 minutes per patient. Nurses based at Lewisham Hospital have completed The Primary Ear Care Centre national diploma in primary ear care and now open access for aural toilet is offered there.(13) It has been found that education was an essential component in formulating a change in practice for general practitioners. The hospital action seems helpful, but most patients would prefer to be treated in general practice rather than be referred to a hospital.(14)

Clear directions for treatment
Patient Group Directives compiled to meet the criteria set out in the Health Service Circular 2000/026 enable clear directions as to the personnel and medication to be used. Failure to comply with the approved PGD could result in prosecution under the Medicines Act. Our PGDs have been approved as directed and in addition by the local pharmaceutical committee and the Medical Defence Union risk management personnel. I'm sure you will agree that following these directions and offering access to a practice nurse/doctor trained in primary ear care, for regular preventive treatment, will decrease ear problems and litigation.

Conclusion
This article has attempted to share good practice and to remove some of the confusion experienced in primary care in the treatment of people with ear problems. Advice on and examples of compilation of Patient Group Directives are available from the author.

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References

  1. Bickerton RC, et al. Survey of general practitioners' treatment of the discharging ear. BMJ 1988;296:1649-50.
  2. Yelland M. Antibiotics for otitis externa. Med J Austral 1991;154:152.
  3. Rowlands S, Devalia H, Smith C,et al. Otitis externa in UK general practice: a survey using the UK general practice research database. Br J Gen Pract 2001;51:533-8.
  4. Acuin J, Smith A, Mackenzie I. Interventions for chronic suppurative otitis media. In: Cochrane Collaboration. Cochrane Library. Issue 4. Oxford: Update Software, 2001.
  5. British National Formulary 41. 12.1.3. Removal of ear wax. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2001. p. 506.
  6. Holmes RC, et al. Medicament contact dermatitis in patients with chronic inflammatory ear disease.J Soc Med 1982;75:27-30.
  7. Rodgers R. Continued education: preventive ear care. Nursing in Practice 2002;(4):71-3.
  8. Rodgers R. Understanding the legalities of ear syringing. Practice Nurse 2000;19:166-9.
  9. Price J. Problems of ear syringing. Practice Nurse 1997;14:126-8.
  10. Sharp JF, et al. Ear wax removal:a survey of current practice. BMJ 1990:301:1251-3.
  11. Roeser RJ, Ballachander BB. Physiology, pathophysiology and anthropology/epidemiology of human ear canal secretions. J Am Acad Audiol 1997;8:391-400.
  12. Oliveira RJ. The active ear canal.J Am Acad Audiol 1997;8:401-10.
  13. Tierney PA, et al. Improving standards in the treatment of acute otitis externa by the use of a treatment protocol and open access to aural toilet. J Laryngol Otol 2001;115:87-90.
  14. Fall M, Walters S, Read S, et al.An evaluation of a nurse-led ear care service in primary care: benefits and costs. Br J Gen Pract 1997;47:699-703.

Resources
Contact the author for advice or discussion on points raised and for general practice seminars and lectures:
Rosemary Rodgers Ear Care Services
Stag Medical Centre
162 Wickersley Road
Rotherham
South Yorkshire S60 3LH
T:01709 830065
E:rorodg1stearcare@aol.com
For nurse training course information send an SAE or phone
The Primary Ear Care Centre
Kiveton Park Primary Care Centre
Chapel Way
Kiveton Park
South Yorkshire S26 6QU
T:01919 772746
F:01909 774934
W:www.earcarecentre.com.uk