Otitis Externa Sample Research
Also known as swimmer’s ear, otitis externa is globally known to be a common condition of adults, children and adolescents that is associated with swimming which may present in the acute, chronic or necrotizing forms. Trauma to the outer ear and prolonged wetness of the ear canal are usually the entry portals for infecting organisms. Therefore, avoiding any of the aforementioned precipitants is the cornerstone of prevention. Major characteristic symptoms that patients often present with are: ear pain and discomfort, which are limited to the external auditory canal. The diagnosis and treatment requires thorough ear canal cleansing alongside hydrocortisone and acetic acid combination which aid in inflammation especially after exposure to humid environments.Otitis Externa Sample Research
Introduction
Otitis externa is a disorder that causes significant morbidity and is characterized by ear pain, ear swelling and decreased hearing. It can either be acute or chronic whereby, acute otitis externa lasts for less than six weeks while the chronic form lasts for more than three months. Typically, most acute cases are usually due to bacterial infections while autoimmune disorders and allergies usually cause the chronic form. Otitis externa is also referred to as swimmer’s ear, and is primarily defined as an infection and inflammation of the auricle, the external auditory canal or both where the tympanic membrane and the pinna are also involved.
The development of otitis externa requires the presence of organisms that can easily infect the skin and some impairment of the skin’s integrity in the ear canal which inspires the occurrence of an infection. However, in cases where the skin may be uninjured and healthy, exposure to pathogens through swimming or submersion in a pond whose water has been contaminated by sewage may set off an episode. Occasionally, after a shower, water may be trapped in the ear canal and constriction thereafter may trap debris giving rise to an infection. Using objects or cotton swabs to clear the ear canal causes skin breaks which increases the risk of the development of otitis externa. This paper discusses otitis media as a pediatric disorder. It will include discussions of its clinical presentation, pathophysiology, diagnosis, differential diagnosis and management plan. A description of the role of advanced practice nurses in prevention, risk reduction, management and possible referrals will also be provided.
Clinical Presentation
A major clinical sign of otitis externa is ear pain which increases in intensity when palpating the tragus or when the pinna is applied some form of traction. However, patients may also present with other signs and symptoms such as: mild to severe otalgia that takes approximately 1-2 days, loss of hearing, pressure or fullness in the ear, edema, narrowing and erythema of the external auditory canal, tinnitus, occasional itching and fever and a clear discharge that becomes purulent and foul-smelling with time (Alizadeh, Rostami & Sadeghi, 2016). Patients are also likely to present with symptoms of cellulitis of the neck, face or lymphadenopathy. It is also likely that patients may have a positive history of exposure to activities that involve water such as swimming or a history that precedes trauma to the ear such as forcefully cleaning the ear using an object or cotton swab (Alizadeh, Rostami & Sadeghi, 2016).Otitis Externa Sample Research
Pathophysiology
Incase moisture is trapped in the external auditory canal; it is likely to cause skin maceration. This moisture can also act as a breeding ground for bacteria. Moisture might be trapped following activities such as swimming in water that is contaminated or even when bathing or a humid climate. When the external auditory canal gets obstructed possibly through excessive debris or cerumen, it can also give rise to infection since it becomes an agent of retaining moisture (Jayakar, Sanders & Jones, 2014). When trauma occurs as a result of forceful cleaning, it promotes the invasion of bacteria to damaged skin.
After the establishment of an infection, what follows is an inflammatory response that occurs alongside skin edema. In the external auditory canal, pus and exudate can appear occasionally as well. In severe cases, this infection is likely to spread and result to wither neck or face cellulitis. In patients who are immune suppressed, otitis externa may progress to the malignant form where bacteria tends to invade soft tissues deep underlying structures and cause temporal bone osteomyelitis (Jayakar, Sanders & Jones, 2014). Consequently, this is a life-threatening condition with a very high morbidity and mortality rate that is currently at 50%.
Primary Diagnosis
Primarily, a clinical history alone is not enough to make the diagnosis of otitis externa. Instead, the external auditory canal should also be visualized using an otoscope for signs of inflammation, edema, narrowing and discharge.Otitis Externa Sample Research
Differential Diagnosis
The most notable differential diagnosis of otitis externa includes: acute otitis media, furunculosis and external ear canal contact dermatitis. Patients with acute otitis media present with ear pain although they might also experience some form of hearing loss. The tympanic membrane might also be erythematous but otoscopy would reveal no mobility of the tympanic membrane (Jayakar, Sanders & Jones, 2014). Contact dermatitis is an allergic reaction to agents which might be present in material used as hearing aid or other topical solutions. Most patients may present with a history of previous use of topical solutions with edema and erythema that extends to the conchal bowl (Jayakar, Sanders & Jones, 2014). Furunculosis usually presents as localized infection of a hair follicle in the ear canal. The symptoms that present in this case are similar to tenderness and otalgia in patients with acute otitis externa.
Diagnostic Processes
Although otitis externa can be diagnosed clinically with a comprehensive history and physical examination, diagnostic tests would help to confirm the diagnosis as well as gauging the response to treatment. First, tympanometry is a test that can be done to help to determine the functioning of the ear (Jayakar, Sanders & Jones, 2014). Despite the fact that it cannot be used determine whether or not a patient can hear, it can help to detect inflammation and eczema-like changes in the ear. Other highly recommended tests include full blood count (FBC) and C – reactive protein test (CRP) (Jayakar, Sanders & Jones, 2014). The ear drainage can also be obtained and be cultured to identify the specific fungus or bacteria causing an infection.
Evidence-Based Management Plan
Since pain is a major characteristic feature, management should start with the administration of painkillers. The most preferred painkiller agents include: paracetamol and ibuprofen since they are also anti-inflammatory agents. Debris in the external auditory canal should immediately be removed and any other contributing factors should be avoided. Topical agents such as hydrocortisone and acetic acid solution can also be administered. Topical agents have proven to be effective in controlling infection and edema (Nuttall, 2016). Antibiotic therapy should be initiated among children with a temperature above 390c and whose clinical response appears to be poor. Antibacterial or antifungal ear drops are the most preferred antibiotic therapy (Nuttall, 2016). Morse specifically, antibiotic agents such as otic ciprofloxacin, dexamethasone or ofloxacin may be used. In patients with malignant otitis externa, surgical debridement of the external auditory canal can be done, especially in cases where the ear has a significant amount of discharge (Nuttall, 2016). In case of an abscess, incision ad drainage should immediately be done.Otitis Externa Sample Research
APN Role in Risk Reduction, Prevention and Management
Advanced Practice Registered Nurses play a critical preventive role in reducing the risk of children frequently getting otitis externa. Essentially, the prevention and risk reduction role played by advanced practice nurses starts with education. They educate patients to avoid insert anything into the ear canal (Kiakojuri et al., 2016). After swimming, APNs can educate patients who are prone to otitis media to dry ears using ear-dryers or alternatively, to use burrow’s solution or dilute acetic acid. Patients should be advised to avoid swimming in water that’s polluted (Kiakojuri et al., 2016).
Follow-Up
Some of the issues that are likely to emerge when managing children with otitis externa include: non-adherence to medication probably due to medication costs and wearing protective gear plugs and observing routine instructions. Some of the primary aspects that can help to determine compliance therefore are the duration of therapy and frequency of dosing. Therefore, a close follow-up should be done after the initiation of treatment to assess for these factors and the patients progress. During follow-up, issues related to medication allergy, severity of any side effects and improvement should also be assessed (Kiakojuri et al., 2016). Children who are as young as 2 years and those with problems in hearing and language should also undergo follow-up exams after treatment to assess for hearing loss.
Client/Family Education
To prevent future otitis externa infection, the patients’ caregivers should be educated that the ear canal has a self-cleaning and drying mechanism which simply takes place through evaporation. Therefore, objects and cotton buds should not be inserted into the external ear canal as they might eventually lead to acute otitis media (Nuttall, 2016). It is also essential that the client and family knows that incase of very mild otitis externa symptoms, one should avoid swimming or washing hair. When swimming, hair shampooing and ear plugs usage are very important in preventing otitis externa. Lastly, individuals should generally avoid swimming in water that’s polluted (Nuttall, 2016).Otitis Externa Sample Research
Referrals
Patient referral to an otolaryngologist (ENT) and a primary care physician after treatment is highly recommended. During the visits, wellness ear checks should be performed to ensure that edema and inflammation is fully resolved and to assess for hearing loss which had occurred previously due to secondary occlusion of the canal (Kiakojuri, et al., 2016).
References
Alizadeh Taheri, P., Rostami, S., & Sadeghi, M. (2016). External Otitis: An Unusual Presentation in Neonates. Case reports in infectious diseases, 2016, 7381564. Doi: 10.1155/2016/7381564
Jayakar, R., Sanders, J., & Jones, E. (2014). A study of acute otitis externa at Wellington Hospital, 2007-2011. The Australasian medical journal, 7(10), 392-9. doi:10.4066/AMJ.2014.2094
Kiakojuri, K., Omran, S. M., Jalili, B., Hajiahmadi, M., Bagheri, M., Shahandashti, E. F., & Rajabnia, R. (2016). Bacterial otitis externa in patients attending an ENT clinic in Babol, North of Iran. Jundishapur journal of microbiology, 9(2). doi:10.5812/jjm.23093
Nuttall T. (2016). Successful management of otitis externa. In Practice, 38(Suppl 2), 17–21. Doi: 10.1136/inp.i1951. Otitis Externa Sample Research