This site is intended for health professionals only

Managing ear problems in primary care

Linda Mills
SRN BMedSci(Hons) Dip(PrimaryEarCare)
Clinical Manager
Primary Ear Care Centre
Rotherham PCT

Many patients visit GPs every day with ear problems; 17% of all GP consultations concern nervous and sensory organ problems.(1) A study initiated by Rosemary Rodgers (former Director of the Primary Ear Care Centre) found, however, that satisfaction was increased when patients were treated by nurses trained in ear care. It also discovered that there was an overall reduction in treatment costs, GP workload, use of antibiotics and referrals to ENT.(2) Many nurses have since studied ear care in some depth and now run their own ear problem clinics, and here I will discuss some of the most frequently seen ear problems in primary care: excessive wax, otitis externa, hearing loss and tinnitus.

Ear examination
Before any ear examination, informed consent should be obtained and a full history taken. This should include: what the problem is, when it started, any previous ENT history, general medical problems, medication, allergies, lifestyle including diet and smoking, family history of ear problems, occupation and history of exposure to excessive noise.
To obtain the best view of the tympanic membrane and to ensure that otoscopy is comfortable for the patient, ear examination should be carried out seated. Best vision will be achieved by using an auriscope with a white halogen fibreoptic light, and by using the largest- sized speculum that will comfortably fit into the external auditory meatus (see Figure 1).(3) Before using the auriscope, the pinna and surrounding scalp should be examined for signs of previous surgery, skin lesions, infection or other abnormalities. If infection is present, use a different auriscope speculum for each ear. Holding the concha of the pinna (the bowl area in the middle), gently pull the pinna upwards and outwards to straighten the meatus. In children it will be necessary to pull the pinna down and back. The best view will be obtained by using the right hand to look in the patient's right ear and the left hand for the left ear. However, otoscopy should be carried out using both hands only if the nurse feels she is able to do this safely.

[[NIP18_fig1_35]]

Documentation
When documenting ear care, ensure each ear is described individually. Write down why the patient has attended, what was seen, what treatment was given and why. Ensure that documentation includes whether the tympanic membrane has been visualised or not, if it is intact and if normal features have been seen: light reflex, handle of malleus, pars flaccida, anterior recess and the annulus.(3) Document the plan for continuing care.

Wax problems
Many people attending the surgery do so because of excessive cerumen (wax) problems. Frequently, patients will have pushed the wax down the meatus with cotton buds or hair clips. One of the components of wax is lipids,(4) so a diet rich in saturated fat could increase the buildup of wax. If possible, educate the patient with the use of a diagram. Explain that wax is important as it provides protection and that ears should be self-cleaning.
If the nurse is trained to do so, she can instrument the wax using a Jobson Horne probe and light source. The wax can be gently scooped out of the meatus using the ring end of the probe, or, by applying a small piece of cotton wool to the serrated end, it can be mopped out. This is a much quicker and less invasive procedure than ear irrigation. At the Primary Ear Care Centre, we have found that by seeing patients who regularly have wax problems more often, we can quickly remove any excess wax by instrumentation and so avoid unnecessary irrigation.
If the wax is too far down the meatus to instrument and it is necessary to irrigate the ear, it is important to ensure that the wax has been softened. We advise the use of room-temperature olive oil to be inserted into the ears using a dropper. The patient is told not to insert cotton wool after the oil, as it will soak it up and so diminish the effect. The length of time the patient needs to instil the oil must be dependent on the nurse's clinical judgement, but a usual length of time would be 3-4 days. Sodium bicarbonate drops are also effective, but they have a drying effect on the meatal skin, so are not really suitable for use in the elderly, who frequently have thin, dry meatal skin. Almond oil is also effective but should be avoided in patients with nut allergies.
Before irrigation it is important to ensure that the patient does not have any contraindications (see Box 1), and also consider special precautions (see Box 1). The Ear Care Guidance Document compiled by Primary Ear Care Centre trainer Hilary Harkin is a comprehensive guide to ear irrigation (see Resources).

[[NIP18_box1_34]]

Ear irrigation
The procedure should be carried out seated, using either a headlight or head mirror and external light source. Following irrigation, the meatus should be dried using cotton wool attached to the serrated end of the Jobson Horne probe.
Before irrigating a child's ears, consider whether the procedure really is necessary, and whether the individual child will be able to sit still throughout. Sometimes it may be more advisable to instil olive oil for a longer period of time to avoid irrigation. However, irrigation is often a quick and effective way of removing a foreign body as long as it is not hygroscopic (will swell in water).

Otitis externa
Otitis externa is an inflammatory condition of the epithelium lining the external auditory meatus. It may also involve the pinna and outer layer of the tympanic membrane. It is frequently bilateral and can spread to the periauricular soft tissues and even the temporal bone. It can be classified as reactive, infective, acute or chronic.(5) Up to 10% of the population are affected by acute otitis externa at some time in their lives.(6) Signs and symptoms of otitis externa include:

  • Irritation.
  • Watery discharge.
  • Keratin debris.
  • Dry, flaky skin.
  • Oedema/inflammation of external auditory meatal walls and possibly the tympanic membrane.
  • Redness.
  • Mild discomfort or pain.
  • Deafness.
  • Inflammation of the external jugular glands.

Patients may suffer from one or a combination of symptoms depending on the type and severity of the otitis externa.

Treatment of otitis externa
As with any ear problem, a thorough history must be taken. This frequently gives an indication of the cause of the infection. The patient may have recently returned from a holiday abroad where they have been swimming in nonchlorinated pools. It is five times more common in swimmers than nonswimmers.(6) Local trauma may be the cause; the patient may be a cotton bud or hair clip user, or there may be a history of skin problems such as eczema or psoriasis. If the probable cause can be ascertained then the patient can be educated about future prevention.
With any type of otitis externa, thorough cleaning of the meatus is the first priority. This can be done by dry mopping (aural toilet) using a Jobson Horne probe and cotton wool, or, if there are no contraindications, by gently irrigating. Treatments for all ear problems should be according to local Patient Group Directions.
Treatment for a dry acute otitis externa (a furuncle) is usually an anti-inflammatory wick, analgesia and systemic antibiotics. For all other types of otitis externa the usual treatment is the use of an antifungal, or antibacterial and corticosteroid ointment or drops. The ointment can be painted onto the meatus or applied on a wick dressing. Systemic antibiotics are usually not indicated for wet otitis externa unless there is a systemic upset or spreading infection.

Tinnitus
Seven to 14% of adults have at some time attended their GP or practice nurse with tinnitus problems, with 1-2.4% of this group finding the condition potentially disabling.(7,8) Most tinnitus is subjective (can be heard only by the sufferer), but occasionally it is objective (may be heard by an examiner). It can range from being an occasional slight nuisance to seriously affecting the person's quality of life. The worst thing you can say to a tinnitus sufferer is that you can't do anything to help them. Instead, you should do the following:

  • Take a history. Find out how long the patient has suffered from tinnitus; was there a trigger such as an episode of stress, illness, exposure to noise, dental treatment or new medication?
  • Does the patient have any other symptoms: ­hearing loss, dizziness, ear problems?
  • Look at the patient's ears; is there an excessive wax buildup? If possible, remove excess wax by instrumentation.
  • Carry out audiometry. If the patient is having hearing problems then providing a hearing aid may be helpful.
  • Give the patient time to express their concerns.
  • Read up about tinnitus so that you can give useful advice (eg, reducing caffeine intake may be ­beneficial). Obtain supporting literature - the RNID and the British Tinnitus Association ­provide a wide variety of patient leaflets about ­tinnitus (see Resources).

Tinnitus can be a symptom of a more serious disorder such as Ménière's disease, acoustic neuroma, vascular abnormality or a neurological problem, so it is important to consider whether ENT referral is required.(9)

Hearing loss
Prevalence of hearing loss in adults rises with age from 3.5% in the 20­-24-year age group(10,11) to over 80% in the over- 80s.(11,12) If a patient attends a primary care clinic because of hearing loss it is probably because they have had the problem for quite some time. There are two main types of hearing loss: conductive, which is caused by a problem in the outer or middle ear, and sensorineural, which involves the inner ear. As with any ear problem, it is important to take a thorough history and examine both ears.
If the nurse is trained to do so, s/he can perform tuning fork tests to ascertain the type of hearing loss and then audiometry to assess the degree of hearing loss. In general, any unilateral or conductive hearing loss should be investigated. If the patient would benefit from a hearing aid they can be referred to either their local NHS audiological centre or a private audiologist. Because some patients may wish to obtain a private "in-the-ear" hearing aid, it is important to investigate local firms so that you can advise which ones may be the most suitable.

Training
Before carrying out any ear procedure it is important that the nurse has adequate training and mentoring and understands the normal anatomy and physiology of the ear in order to be able to recognise the abnormal.(13)
The Primary Ear Care Centre has trainers throughout the UK who teach various study days. For nurses who are holding their own ear clinics, a five-day diploma in primary ear care is available at the Primary Ear Care Centre's headquarters.

Conclusion
Primary care nurses can do much to alleviate the pain,  discomfort and embarrassment that ear problems can cause. A clinic can be started with minimal costs and instruments: a few Jobson Horne probes, Tilley forceps, a Henkle forcep, a headlight, an electronic irrigator, a Noots receiver, good-quality cotton wool and ribbon gauze. Ideally, dedicated time should be set aside for ear care, so that instruments can be set out and the room layout adapted if required. At the Primary Ear Care Centre, we have 20-minute appointments that allow time for thorough history taking and time to look in both ears and treat accordingly. Sometimes we still run over! It is important to allow for time to talk with the patients, as they frequently require "ear care education" to prevent further problems. It may also be necessary to provide advice and support for patients with hearing loss or tinnitus.

References

  1. OPCS. Morbidity Statistics from General Practice - 4th National Study 1991-1992;1995.
  2. Fall M, Walters S, Reid S, et al. An evaluation of nurse-led ear care service in primary care: benefits and costs.Br J Gen Pract 1997;47:699-703.
  3. Rodgers R. Understand the legalities of ear syringing. Practice Nurse 2000;19:166-9.
  4. Roeser R, Ballachanda B. Physiology, pathophysiology and ­anthropology/epidemiology of human ear canal secretions.J Am Acad Audiol 1997;8:391-400.
  5. Robertson D, Bennett J. The general practice management of otitis externa. J R Army Med Corps 1995;138:27-32.
  6. Raza S, Denholm S, Wong J. An audit of the management of acute otitis externa in an ENT casualty clinic.J Laryngol Otol 1995;109:130-3.
  7. Burke S, Richmond M. Tinnitus: ­prevalence, causes and ­treatment approaches. Geriatr Times 2003 Jul/Aug;IV: Issue 4.
  8. Vesterager V. Tinnitus - ­investigation and management. BMJ 1997;314:728-31.
  9. Crummer R, Hassan G. Diagnostic approach to ­tinnitus.Am Fam Physician 2004;69:120-6.
  10. Davis A. Hearing in adults. London: Whurr Publishers; 1995.
  11. Irwin J. Hearing aids in adult patients. Practitioner 2004;248:110-5.
  12. Davis A. The epidemiology of hearing in an ageing ­population. In: Pathy MSJ, editor. Principles and practice of ­geriatric medicine. 3rd ed. Chichester: John Wiley and Sons; 1998. p. 1087-92.
  13. Rodgers R. Preventative care. Occup Health 2003 Feb;55:26-30.

Resources
Primary Ear Care Centre  
W:www.earcarecentre.com
or W:www.entnursing.com.
RNID
W:www.rnid.org.uk
British Tinnitus Association
W:www.tinnitus.org.uk