Managing otitis externa in nurse-led clinics

skin of the outer ear canal, often associated with underlying dermatological conditions.1,2 Symptoms include discharge from the ear, reduced hearing, itch, and mild to severe pain. It may present as an acute episode, or may develop into a chronic condition causing significant adverse effects on a patient’s daily activity.3,4 Optimal treatment for otitis externa requires suction of the external auditory canal under microscopic vision to remove any cerumen, keratin or infective debris present, allowing thorough inspection of the tympanic membrane and a guided culture swab to establish an accurate microbiological diagnosis. Microsuction also delivers symptomatic relief from the aural blockage and impaction. Topical preparations are the first-line of treatment for otitis externa, targeting the affected tissue particularly when applied following microsuction clearance. Unfortunately, optimal treatment for many patients is not accessible as it is labour intensive and the necessary equipment is not available in community practices or general emergency departments (ED). Therefore, a variety of topical and systemic antimicrobials are often given based on an empirical clinical assessment, especially in patients with chronic otitis externa. This can foster microbiological resistance as well as induce hypersensitivity reactions in the skin of the external auditory canal.5,6,7 study The aim of this study was to prospectively audit the implementation of an evidence-based treatment protocol on the management of otitis externa patients in a specialist ED. Otitis externa patients account for 25% of all attendees and frequently require multiple visits. Additionally, the clinic offered an ideal environment for one-to-one consultant-provided nurse training in the clinical assessment, diagnosis and treatment of these patients. Patient selection criteria Six patients were referred from the ED on a first-come first-served basis until the allocated number of slots were filled for any given week. The criteria for referral were: • Diagnosis of otitis externa • Treated at least once in an emergency department and estimated to require further treatments • Patients with tympanic membrane perforation or middle ear diseases were excluded. Data was recorded on previous history and treatments for otitis externa, history of water exposure or water sports, efforts to waterproof ears, history of itchy ears, habit of scratching/cleaning ears using fingers, cotton buds or other objects, and history or diagnosis of dry skin or other dermatological condition. treatment protocol A critical element of the treatment protocol was to minimise the incidence of iatrogenic effects of treatments. As some studies have shown steroid-only treatments to be as effective as combination anti-microbial and steroid,8,9 the treatment protocol was predicated on meticulous microsuction and the initial use of steroid-only treatment, except in presence of severe otitis externa, or active bacterial or fungal infection, with recent microbiology culture suggestF or um E N T Managing otitis externa in nurse-led clinics