PHAR2822 Common Ear Conditions JB 2024 PDF

Ear Health Common Ear Conditions in Pharmacy Presented by Jocelyn Bussing BPharm DBM Grad Cert Ed MPhil Candidate Sydney School of Pharmacy The University of Sydney Page 1  Objectives After this lecture and the related tutorial, students should be able to: – Describe...

Ear Health Common Ear Conditions in Pharmacy Presented by Jocelyn Bussing BPharm DBM Grad Cert Ed MPhil Candidate Sydney School of Pharmacy The University of Sydney Page 1  Objectives After this lecture and the related tutorial, students should be able to: – Describe the basic anatomy of the ear – Identify signs, symptoms and causative pathophysiology of common ear conditions. – Describe Application of ear drops – Apply a systematic reasoning process to address the range of health and drug- related problems that present in Pharmacy involving ear conditions – Apply knowledge to clinical cases The University of Sydney Page 2  Assessing Common Ear Conditions The University of Sydney Page 3  Ear Anatomy TIP: Use patient focused http://www.handsandvoices.org/resources/coGuide/images/theEar.gif language The University of Sydney Page 4 Signs & symptoms Source: Community Pharmacy 5th edition - P.Rutter, This is an important reference for all of our Minor Ailment conditions in PHAR2911 and an excellent resource for passing your Pharmacy Board exam as an intern. The University of Sydney Page 5  Assessing an ear condition – Gathering Information Using the tables on the previous slide from your textbook – develop open ended questions to ask about ear symptoms: Examples Describe the symptoms? E.g. Pain, gradual hearing Loss, discharge, itchiness Any other symptoms? Dizziness, tinnitus, fever How long have they been present? Have you tried any treatments? TIP: How bothersome Have you had a recent injury? Eg whilst cleaning the ears? are the symptoms The University of Sydney Page 6 Assessing an ear condition – External Examination Video Demo from Pre-work External Examination LINK – Without an otoscope , we must use information gathering &an external examination to assess the ear condition. 1. Wash hands 2. Inspect external ear for redness, swelling or discharge. 3. Check for tenderness in the area behind the pinna (mastoid area) 4. Check for tenderness in the pinna and tragus. NB The pinna is manipulated differently for adults and children to view the ear canal and instil ear drops. Down for children and up and back for adults. The University of Sydney Page 7 Assessing an ear condition – Differentiation, Severity & when to refer What causes ear pain - Patient information Health Direct-https://www.healthdirect.gov.au/earache#causes Earache (sore ear) is a common complaint, especially in children. It is most commonly caused by an ear infection of the middle Check your symptoms ear or outer ear. Other common causes of ear pain are: changes in air pressure, such as when you take off or land in a plane an object in the ear (a ‘foreign body’) an injury to your ear or eardrum a build up of ear wax Ear pain can also come from a problem in another part of your body, such as: referred pain from an infection near the ear, such as sinusitis or tonsillitis problems with the jaw joint (called the temporomandibular joint or TMJ) dental problems, such as teeth grinding or a dental infection The University of Sydney Page 8  Common Ear Complaints 1. Impacted wax 2. Otitis externa – Swimmer’s Ear 3. Otitis media – Middle Ear Infection, Including Glue Ear 4. Perforation & Trauma 5. Perichondritis Note – Other ear conditions we need to know about for differentiation are covered in the Week 3 tutorial pre-work video The University of Sydney Page 9 1. Ear Wax - Impacted What are the properties of Ear wax – produced by the glands in the skin lining the ear canal (EAM). – contains less than 50% of fatty matter derived from secretions of the sebaceous ceruminous glands. – Cerumen everts a protective effect by maintaining acid pH of 5.2- 7 in EAM and lubricates the canal. – Greater than 50% of wax consists of desquamated epithelium, foreign matter and shed hairs. This non-fatty material forms a matrix holding together the granules of fatty matter to form the ceruminous mass. It normally naturally moves outwards from the ear drum. ie. the ear is normally self cleaning. The University of Sydney Page 10 1. Ear Wax - Impacted What is Impacted Ear Wax? Occasionally , ear wax can build up and harden. Some known causes are: – Interuption of the natural process by cleaning the ears with ear buds or “other” items. – Age related decrease in cerumen producing glands causes an Symptoms include: increase in drier ear wax in elderly – earache patients. – blocked ear or feeling of fullness – gradual hearing loss – ringing in the ears (less common) – dizziness (less common) The University of Sydney Page 11 1. Ear Wax - Impacted Cerumol Formulation – Now free of Arachis Oil Treatment: Over 30% of ears impacted with wax will clear without intervention in 5 days Cerumenolytics – Oil based preparations that aid in softening and dispersing wax by emulsification. Because of their low surface tension and miscibility, rapidly penetrate the dry matrix of the ceruminous mass, reducing the solid matter to a semi-solid debris. This can be ejected by normal physiological processes or in more severe cases syringed away by a medical professional. Note: not current scope of practice for pharmacists Dosage: specific for formulation – please look up your resources including PI + AMH + MIMS Online Examples: TIP: Check product –docusate (Waxsol), indications and –carbamide peroxide (Ear clear), appropriate age –sodium chloride spray (Audiclean) The University of Sydney Page 12 1. Ear Wax – AMH Online Ear wax – Wax build-up may cause symptoms (deafness, pain) and is common in older people, young children and those with cognitive impairment; it is associated with hearing aids and cotton bud use. Practice points – avoid using cotton buds and ear candles – over 30% of ears impacted with wax will clear without treatment within 5 days – cerumenolytics (including water and saline) and/or syringing may be used to treat impacted ear wax: – direct comparative trials between interventions are lacking – there is no good evidence for appropriate duration of treatment with ear drops alone; a reasonable guide is to use 2–5 drops once or twice daily into the affected ear for 3–5 days – gentle syringing with warm (body temperature) water or sodium chloride 0.9% solution may help loosen and remove wax; if wax appears hard and impacted, consider using cerumenolytic drops 15 minutes before syringing – avoid syringing if there is a history of otic surgery, perforated eardrum or otitis (externa or media); in particular, people who are deaf in one ear should not have the good ear syringed https://amhonline-amh-net-au.ezproxy1.library.usyd.edu.au/chapters/ear-nose-throat-drugs/drugs-ear-wax/ear-wax The University of Sydney Page 13 2. Otitis Externa – Swimmer’s Ear This is a common generalized inflammation of the EAM. It is usually acute but can be chronic in children, swimmers and water sports or Surfer’s ear. Commonly a bacterial or fungal infection of the ear canal. Causes: Trauma, dermatitis or prolonged exposure of the ear to moisture causing maceration eg regular swimming in unclean water. Symptoms: irritation, itchy ear, pain (made worse by movements…eg: chewing), feeling of pressure or fullness in the ear, discharge (usually clear), mild hearing loss See slide 5 table 3.1 & 3.2 – Community Pharmacy Text Treatment: Prescription: Antibacterials, corticosteroids, antifungals can all be used depending on severity. The University of Sydney Page 14 2. Otitis Externa – Swimmer’s Ear Prevention & Pain Management: Hygiene and drying techniques are important to prevent another infection & for at risk or chronic patients 1. Antiseptic drying agent. Restore acidic pH of external auditory canal and inhibit microbial growth Eg: Acetic acid (Aqua ear) – 4-6 drops in each ear after swimming or bathing 2. Keep ear dry. During treatment use cotton wool balls smeared in vaseline while showering or bathing When to refer: 3. Use ear plugs if swimming. OTC treatment is limited to very early presentations. 4. OTC pain relief for acute pain. Consider Pain and Duration when deciding whether to refer. Avoid – Local trauma: eg cleaning ears Hearing Impairment Inflammation of the Pinna Mucopurulent discharge Feeling unwell The University of Sydney Page 15  2. Otitis Externa – Guidelines Otitis Externa – AMH *Give all patients adequate pain relief, eg an NSAID. If the pain is severe, consider early Acute Otitis Externa-diffuse - eTG referral to an ENT specialist. – Keep ear canal dry *Keep external ear canal dry by meticulous – Rx combination corticosteroid and antimicrobial ear drops gentle cleansing and drying with tissue spears (rolled tissue paper). Do this 2–4 times daily if – Ear clean (HCP) possible (but at least once daily). – Pain management – Ear wick if complete occlusion (HCP) – Oral antibiotics may be necessary if fever present or special patient group. – Keep ear dry for 2 weeks after treatment – If symptoms do not improve, return to your doctor. – See the link below for Antimicrobial regimens https://tgldcdp-tg-org-au.ezproxy.library.sydney.edu.au/viewTopic?topicfile=otitis- externa&guidelineName=Antibiotic&topicNavigation=navigateTopic The University of Sydney Page 16  3. Otitis Media “Infection of the middle ear cavity is common, especially in children. It is abrupt in onset; symptoms include pain and fever and irritability (in infants); it is caused by viruses and/or bacteria (most commonly Streptococcus pneumoniae, Haemophilus influenzae or Moraxella catarrhalis).” AMH Online Otitis media is inflammation of the middle ear with a build-up of fluid due to a bacterial or viral infection. Otitis media often starts from a common cold. Otitis media causes pain and sometimes fever. There may be a discharge from the ear. Signs include crying, ear-pulling and irritability. Antibiotics may be needed, though not always. This depends on the age of the child, whether there is a fever and the duration of the problem. If symptoms are mild – the analgesic management for the first 1-2 days is recommended and commencement of antibiotics only if there is no symptom improvement. Early antibiotic treatment may hasten recovery and reduce complications The University of Sydney Page 17 3. Otitis Media At Risk Patients Aboriginal and Torres Strait Islander populations: – Indigenous children are at greatly increased risk of severe OM – Severe or recurrent OM will improve with improved living standards – Encourage attendance at local health clinic as soon as possible whenever a child develops ear pain or discharge. – Frequent examinations – especially if sick – Pharmacists can support Aboriginal and Torres strait islander health staff to have a greater impact on severe OM Week 2 reading E.McDonald: Menzies School of Health Research : Evaluation of implementation of best practice models of care based on the updated recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations. last updated Otitis Media Guidelines App - Interactive web page/APP https://otitismediaguidelines.com/#/start- main The University of Sydney Page 18 3. Otitis Media AMH Other at risk patient groups for severe or recurrent OM: – those with otorrhoea or severe or systemic symptoms, and – those with risk factors for serious complications (eg Down syndrome, cleft palate, cochlear implants, the immunocompromised https://amhonline-amh-net-au.ezproxy1.library.usyd.edu.au/chapters/ear-nose-throat- drugs/drugs-ear-infections/otitis-media?menu=vertical Suppurative Otitis Media – an example of severe Most severe form of otitis media, characterised by a chronically perforated eardrum and discharge over several weeks (also known as active chronic otitis media). Bacteria present differ from those in acute otitis media and include P. aeruginosa, E. coli, S. aureus, Proteus mirabilis and Klebsiella spp. The University of Sydney Page 19 3. Otitis Media - Guidelines Acute otitis media – eTG Acute Otitis Media – AMH – Adequate analgesia – Adequate analgesia – Antibiotic therapy – Oral antibacterials “For most children with acute otitis media, antibiotic therapy can be – “For most patients who are only mildly unwell, consider safely withheld. However, antibiotic therapy is required in the following symptomatic treatment with analgesics for the first 24– groups: 48 hours; start oral antibacterials only if symptoms have not – infants younger than 6 months improved.” – children younger than 2 years with bilateral infection – Special patient groups, early AB treatment – children who are systemically unwell (eg lethargic, pale, very – AB of choice – amoxycillin (or cefuroxime if Ci-d) irritable); fever alone is not an indication for antibiotic therapy – children with otorrhoea https://amhonline-amh-net- – Aboriginal and Torres Strait Islander children—for treatment au.ezproxy.library.sydney.edu.au/chapters/ear-nose-throat- recommendations, see the Recommendations for clinical care drugs/drugs-ear-infections?menu=vertical guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations [Note 1] – children at high risk of complications (eg immunocompromised children).” Acute Otitis Media Clinical Practice Guidelines in children – Shared decision making https://www.rch.org.au/clinicalguide/guideline_index/ac – Preventing Recurrent bacterial otitis media https://tgldcdp-tg-org- ute_otitis_media/ au.ezproxy.library.sydney.edu.au/viewTopic?topicfile=otitis-media The University of Sydney Page 20  3. Otitis Media – Glue Ear Glue ear is a type of chronic OM that mainly Otitis media and glue ear occur is a affects children. health concern in Australian Indigenous children, and continues to be part of the – long-term build-up of thick or sticky fluid in the strategy for health, education and closing middle ear, behind the eardrum. the gap. – hearing impairment often the only symptom – https://www1.health.gov.au/internet/main /publishing.nsf/Content/B8A6602C7714B – can delay speech development and make 46FCA257EC300837185/$File/Recomme socialising and learning difficult. T ndation-for-clinical-guidelines-Otitis- Media.pdf – Often resolves with no treatment – but it is important that the ear is checked by a – Jervis-Bardy, J., Sanchez, L., & Carney, A. (2014). Otitis media in Indigenous doctor to see if treatment is needed, especially Australian children: Review of if there are speech and/or hearing difficulties. epidemiology and risk factors. The Journal Sometimes children will need to have grommets of Laryngology & Otology, 128(S1), S16- S27. doi:10.1017/S0022215113003083 inserted to allow drainage of fluid. Resources: https://www.schn.health.nsw.gov.au/fact-sheets/ears-glue-ear-and-grommets The University of Sydney Page 21  3. Otitis Media – Grommets for Glue Ear A ‘grommet’(ear tube) is a very small tube that is inserted surgically into the eardrum to let fresh air into the middle ear. – Once air can enter the middle ear it helps to improve your hearing by allowing the tiny bones of hearing and ear drum to move freely again. – Hearing should improve immediately. – Grommets usually fall out of the eardrum after 6-12 months and the hole in the eardrum then y heals quickly when the Picture source: grommets fall out. https://www.kidshealth.org.n z/grommets A pharmacist often needs to assist with swimming protection for patient’s with grommets. Ear plugs are recommended to keep the ear dry – free of contaminated water and to prevent water entering the middle ear via the grommet. They are best supported with a swimming cap or an ear wrap-type headband. The University of Sydney Page 22  3. Otitis Media – Resources * Guidelines Focus on Indigenous Australians with otitis media – New online web page 5th August 2021 – Built on the evidence based guidelines developed since 2017 – App for Smart devices – Audio translations: – Week 3 – explore in tutorial https://otitismediaguidelines.com/#/start-main The University of Sydney Page 23  4. Ear Drum perforation A perforated eardrum happens when you have a perforation (a tear, or rupture) of the tympanic membrane. Signs include: – hearing loss – pain in the ear- especially linked to trauma or severe otitis media – discharge of fluid - clear, mucopurulent or bloody – Tinnitus or Vertigo – earache or pain that suddenly goes away- due to pressure release when the rupture occurs – air coming out of your ear when you blow your nose – fever if there is otitis media The University of Sydney Page 24  4. Ear Drum perforation - causes – Otitis Media – Barotrauma - sudden changes in air pressure (flying, diving) – Acoustic trauma - sudden loud noise eg explosion – Injury – mechanical damage eg ear bud, foreign body – Hard blow to head or ear – sports, slap, punch, car accident – Ear syringing (less common) – Eustachian tube disorder (less common) Referral required - to GP. Whilst they do resolve, treatment may be required and hearing changes assessed. The University of Sydney Page 25  5. Perichondritis Ear + Skin Is the inflammation of the perichondrium – thin tissue of the Pinna supports the underlying cartilage & infection of the tissue covering the external ear (pinna or auricle) Causes: Injuries, insect bites, burns, piercing, surgery or a boil (furuncle) Symptoms: redness, pain, swelling, fever, pus. Referral for treatment if more than mild. Treatment can include: – Antibiotics and corticosteroids – Removal of foreign objects, especially ear piercings through the cartilage part of the auricle – Warm compresses and incision and drainage of Image sources 0822 https://www.ohniww.org/ear-piercing-perichondritis/ abscesses https://my.clevelandclinic.org/health/diseases/23222-perichondritis – Pain relievers Liu, Z. W., & Chokkalingam, P. (2013). Piercing associated perichondritis of the pinna: Are we treating it correctly? The Journal of Laryngology and Otology, 127(5), 505-8. doi:http://dx.doi.org/10.1017/S0022215113000248 The University of Sydney Page 26 5. Perichondritis Ear Piercing – Complications from ear piercing are common – Include infection and allergic reactions to metals eg nickel – Piercing causes mild redness swelling and crusting as it heals and usually takes up to 6-8 weeks. But depends on the part of the pinna pierced. Treatment for Mild perichondritis – Prevent infection by washing area twice a day. – Treat any infection locally and do not remove the earing if possible to keep the whole open. – Infections of the cartelage at the top of the pinna are more serious and should be referred. – Watch for allergic dermatitis. – hydrocortisone is appropriate topically. – Refer immediately if moderate to severe presentation. The University of Sydney Page 27  Common Ear Conditions Practice Tips The University of Sydney Page 28  Administration of Ear Medications – introduced in Week 2 tutorial AMH Online Administration of ear medications Example: – If possible, the patient should receive help. The ear should be clean and CMI Chloromycetin Ear Drops dry (use rolled tissue paper spears) and the patient should lie with the You may warm to body temperature, but no affected ear uppermost. higher, by holding the bottle in your hand for a few minutes. – Ear drops are preferred; warm container in cup of warm water if Lie down or tilt your head so the infected ear is necessary to reduce viscosity. Instil directly into ear canal then remain in facing upwards. position for 3–5 minutes; gentle massage or pressure on the tragus may Place the required number of drops into the ear aid penetration of the drops. canal. – If the ear canal is too swollen to allow drug entry, drops may be Keep the ear facing up for about 5 minutes to instilled via a clinician-inserted wick or ribbon gauze. This should be allow the medicine to coat the ear canal. For young children who cannot stay still for 5 reviewed every few days until the swelling subsides; the wick may then minutes, try to keep the ear facing up for 1 to 2 fall out on its own accord or be removed. minutes. – Ear ointments are used less often as they may accumulate and cause To keep the medicine as germ-free as possible obstruction of the ear canal. A small amount of ointment should be do not touch the dropper to any surface gently squeezed into the ear canal; it may also be used on or around (including the ear). the ear. Close the container tightly after use.” https://amhonline-amh-net-au.ezproxy1.library.usyd.edu.au/chapters/ear- Source: https://www.nps.org.au/assets/medicines/03d62278-ae1b- nos-throat-drugs/drugs-ear-infections/otitis-externa#otitis-externa-03 The University of Sydney 4234-9374-a53300fec809.pdf Page 29  Discussing Hearing Loss with consumers Hearing loss occurs when one or more Causes: parts of the ear and/or the parts of – Natural ageing process the brain that make up the hearing – Genetic predisposition pathway do not function normally. The causes of hearing loss come in many – Middle er infections forms and can have multiple causes – Damaging noise with an individual having a unique – Head injuries or trauma type of hearing loss. – Chemical exposure It can range from mild to profound – Medication ototoxicty hearing loss. – Head injury or trauma – Auditory processing disorder – Any combination of the above! The University of Sydney Page 30  Communication skills and hearing loss – It’s important to know if you have a hearing loss, as it can reduce your ability to learn, work, listen, and talk with family, friends and workmates. – hearnet.org.au Resources: Impact of hearing loss on daily life and the workplace https://www.ncbi.nlm.nih.gov/books/NBK207836/ Generic quality of life in persons with hearing loss: a systematic literature review Nordvik, Ø., Laugen Heggdal, P.O., Brännström, J. et al. Generic quality of life in persons with hearing loss: a systematic literature review. BMC Ear Nose Throat Disord 18, 1 (2018). https://doi.org/10.1186/s12901-018-0051-6 https://hearnet.org.au/ http://www.betterhearing.org.au/wp-content/uploads/2018/07/Better-Hearing-Australia-VIC-Fact-Sheet-I-think-I-might-have-a- hearing-loss.pdf The University of Sydney Page 31  References – Text: Community Pharmacy - P.Rutter, D.Newby edition 5 2021 – https://www.mydr.com.au/pharmacy-care/ear-problems-self-care – https://amhonline-amh-net-au.ezproxy1.library.usyd.edu.au/chapters/ear-nose-throat-drugs/drugs-ear- wax/ear-wax – https://amhonline-amh-net-au.ezproxy1.library.usyd.edu.au/chapters/ear-nose-throat-drugs/drugs-ear- infections/otitis-externa#otitis-externa-03 – https://tgldcdp-tg-org-au.ezproxy.library.sydney.edu.au/viewTopic?topicfile=otitis- externa&guidelineName=Antibiotic&topicNavigation=navigateTopic – https://healthinfonet.ecu.edu.au/ – E.McDonald: Menzies School of Health Research : Evaluation of implementation of best practice models of care based on the updated recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations. last updated – Otitis Media Guidelines App - Interactive web page/APP https://otitismediaguidelines.com/#/start-main The University of Sydney Page 32  References – https://amhonline-amh-net-au.ezproxy1.library.usyd.edu.au/chapters/ear-nose-throat-drugs/drugs-ear-infections/otitis- media?menu=vertical – https://www.schn.health.nsw.gov.au/fact-sheets/ears-glue-ear-and-grommets – https://www1.health.gov.au/internet/main/publishing.nsf/Content/B8A6602C7714B46FCA257EC300837185/$File/Recommendation- for-clinical-guidelines-Otitis-Media.pdf – Jervis-Bardy, J., Sanchez, L., & Carney, A. (2014). Otitis media in Indigenous Australian children: Review of epidemiology and risk factors. The Journal of Laryngology & Otology, 128(S1), S16-S27. doi:10.1017/S0022215113003083 – Liu, Z. W., & Chokkalingam, P. (2013). Piercing associated perichondritis of the pinna: Are we treating it correctly? The Journal of Laryngology and Otology, 127(5), 505-8. doi:http://dx.doi.org/10.1017/S0022215113000248 – Liu, Z. W., & Chokkalingam, P. (2013). Piercing associated perichondritis of the pinna: Are we treating it correctly? The Journal of Laryngology and Otology, 127(5), 505-8. doi:http://dx.doi.org/10.1017/S0022215113000248 – https://www.racgp.org.au/afp/2016/september/ear-discomfort-in-a-competitive-surfer/ – Lockwood AH, Salvi RJ, Burkard RF. Tinnitus. N Engl J Med 2002;347:904-10. – Langguth B, Elgoyhen A. Current pharmacological treatments for tinnitus. Expert Opin Pharmacotherapy 2012;13;2495-509. The University of Sydney Page 33