What additional information (e.g., clinical findings, laboratory test results) will confirm the diagnosis?
Other clinical findings necessary to confirm the diagnosis include the presence of otorrhea, erythema, itchiness, and conductive hearing loss. The ear canal’s skin is often erythematous as a result of edema, and on rare occasions, the pinna may protrude because of the swelling (Wiegand et al., 2019). Otitis is a polymicrobial infectious disease that causes an inflammatory response in the external auditory canal, auricle, and the tympanic membrane’s outer surface (Gokale et al., 2017). The presence of ear fullness or pressure and lymphadenopathy around the neck region is indicative of the diagnosis. A tuning fork examination typically confirms conductive hearing loss, while otoscopic examination identifies swelling in the ear canal (Wiegand et al., 2019). It is important to swab the secretions for culture and resistance testing.
What is the likely diagnosis? What are your differential diagnoses for this patient?
The most likely diagnosis for this patient is acute diffuse otitis externa. The differential diagnoses include acute otitis media, psoriasis, TMJ syndrome, contact dermatitis of the external ear, furunculosis, carcinoma of the ear canal, and Herpes zoster oticus.
What is (are) the desired treatment outcome(s)?
The aim of treatment is to return the skin of the ear canal to its natural state. In addition, it is vital to restore the typical production of cerumen, which is vital for normal ear health (Wiegand et al., 2019). It is critical to ensure that the patient is free of pain and any hearing anomalies are eliminated.
What non-pharmacological therapy would you recommend?
Atraumatic cleansing of the external ear is an effective non-pharmacological intervention suitable for the management of acute otitis externa. It involves the removal of exudates and cerumen, which may contain toxins such as the pseudomonas exotoxin that is implicated in the maintenance of the inflammatory process (Wiegand et al., 2019). In addition, the external ear contents may limit the effectiveness of topical medications. The procedure is conducted under microscopic vision using an aural hook or suction to avoid injuring the ear canal. After ruling out a tympanic membrane defect, distilled water or normal saline can be used to rinse the ear canal (Wiegand et al., 2019). Patients must be cautioned against cleaning their own ears with cotton swabs in view of the fact that the trauma caused promotes bacterial invasion.
How would your pharmacotherapeutic plan differ, based on special population patients (such as children, obstetrics, geriatrics, etc.)?
Certain precautions must be taken when managing special populations with a diagnosis of otitis externa. For instance, external ear lavage is discouraged in individuals with a history of diabetes because it could induce malignant otitis externa (Medina-Blasini & Sharman, 2020). It is worth noting that oral antibiotics have no proven benefits in the management of the disease except in patients with immunocompromised states (Pontefract et al., 2019). Therefore, they can be used in patients diagnosed with diabetes, HIV/AIDS, concurrent otitis media, or when malignant otitis externa is suspected (Medina-Blasini & Sharman, 2020). Steroid-containing medications should be avoided in individuals younger than 18 years of age (Wiegand et al., 2019). These measures are meant to limit the incidence of complications associated with the management of the illness.
What pharmacotherapeutic plan (include prescription and non-prescription drugs) would you design for this patient (specific to the chapter you are currently reading)?
The pharmacotherapeutic plan, in this case, will involve confirming the diagnosis and verifying whether or not the disease process is limited to the external auditory canal. It is vital to establish whether or not the canal is blocked. In case of blockage in the absence of auditory canal perforation, topical antiseptics such as acetic acid and silver nitrate will be administered. In addition, antimicrobial treatments such as ciprofloxacin and polymyxin B will be used to manage the infection. Finally, analgesic drugs such as phenazone and procaine will be administered to reduce pain in the affected ear. In the event perforation is suspected, non-ototoxic medications must be used in the management of the disease. Therefore, polymyxin B, phenazone, procaine, and Fluocinolone acetonide must be avoided in these patients (Wiegand et al., 2019). These medications may worsen the prognosis in individuals with perforated tympanic membranes.
The rationale for pharmacotherapy to include mechanism(s) of action list drug(s), dose, route of administration, frequency, duration of treatment, and one monitoring parameter.
The use of topical medications in the management of otitis externa is often successful in a majority of patients. Regardless of the drugs used, approximately 65% to 90% of the patients experience clinical resolution within 7 to 10 days (Medina-Blasini & Sharman, 2020). The first option for management is the topical administration of 2 to 4 drops of 7500 IU of polymixin B combined with 3500 IU of neomycin sulfate and 0.02 mg of gramicidin in the affected ear for a maximum of seven days (Wiegand et al., 2019). The second option is the administration of 4 drops of 3 mg of ciprofloxacin/ml combined with 1mg dexamethasone/ml daily for seven days. Quinolones, aminoglycosides, and polymixins lead to rapid symptom relief and are effective against staphylococcus aureus and Pseudomonas aeruginosa, which are implicated in otitis externa. Ciprofloxacin does not cause local irritation and is highly effective in managing the illness. Assessing hepatic and renal function is vital in patients on ciprofloxacin that develop tendinitis or altered mental status.
What are the clinically significant adverse effects and drug interactions for the agents discussed?
Some of the medications recommended in the treatment of otitis externa have adverse effects. For instance, neomycin is ototoxic and must only be administered in cases where tympanic perforation has been eliminated (Wiegand et al., 2019). It also causes contact dermatitis in approximately 15-30% of patients (Wiegand et al., 2019). Prolonged ciprofloxacin use predisposes individuals to drug resistance which increases their susceptibility to a variety of infections.
How will you monitor the patient’s response to therapy?
It is essential to establish a clinical response to therapy within 48-72 hours. There should be a reasonable reduction in pain swelling and the amount of exudates in the affected ear. In addition, the patient should experience improved hearing and reduced fullness after the administration of medication. Repeating an otoscopic examination and conducting a tuning fork examination are vital since they provide objective evidence of the patient’s response to therapy. If no response is noted, it is vital to re-examine the patient and confirm that the diagnosis is correct. If otitis externa is confirmed, it is crucial to change the treatment for better results. In the event other illnesses are diagnosed, appropriate treatment should be instituted as soon as possible.
How will you counsel your patient about the pharmacotherapeutic plan?
It is essential to stress the importance of adhering to the prescribed dosages and schedule for treatment. Pointing out the potential side effects of using the medications is important. This will allow the patient to differentiate between worsening symptoms and drug-induced sensations. The patient must also be informed of the signs of treatment failure so that they can seek further assistance. Substances capable of interacting with the administered drugs must be specified to prevent complications. It is important to allow the client to raise their concerns about the medication. These may include cost, preferences, or risks to special populations. Ensuring that the patient understands the effects of the medications and gives informed consent to treatment are essential steps in managing otitis externa.
References
Gokale, S. K., Anushka, D., Solabannavar, S. S., & Sonth, D. (2017). Bacteriological study of acute otitis externa in a tertiary care hospital of a district in North Karnataka, India. International Journal of Current Microbiology and Applied Sciences, 6(9), 981–985.
Medina-Blasini, Y., & Sharman, T. (2020). Otitis Externa. StatPearls – NCBI Bookshelf. Web.
Pontefract, B., Nevers, M., Fleming-Dutra, K. E., Hersh, A., Samore, M., & Madaras-Kelly, K. (2019). Diagnosis and antibiotic management of otitis media and otitis externa in United States veterans. Open Forum Infectious Diseases, 6(11), 1–7.
Wiegand, S., Berner, R., Schneider, A., Lundershausen, E., & Dietz, A. (2019). Otitis externa. Deutsches Arzteblatt International, 116(13), 224–234.