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Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Tuesday, June 2, 2020

Resolve Otitis Externa Fast with an Ear Wick

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​Emergency providers expeditiously sift and sort patients on their shifts and streamline procedures like how to place an ear wick in a patient with otitis externa, a quick and useful procedure for a patient who will reap the rewards.

Standard ear wicks. The material is made from a dehydrated sponge composed of hydroxylated poly(vinyl acetate). It increases in size when liquid is applied. Photo by M. Roberts.

Otitis externa can cause significant swelling, irritation, pruritis, and pain to the ear canal. Occasionally, the canal is so swollen it may be difficult to administer ear drops. An ear wick can be inserted between the swollen canal walls to help instill medication and keep the medication around longer to assist with healing.

An ear wick is hard when you place it in the ear, and it softens and expands as soon as it is moistened. It can be used for several days, and an additional one can be inserted by the patient if it falls out. It should be noted that additional bacteria can penetrate ear wicks, but this can be prevented by continuous application of antibacterial ear drops. Ear wicks need priming with six drops of the antibiotic before starting an at-home regimen so the initial dose is fully absorbed. (J Laryngol Otol. 2017;131[9]:809.)

Causes of Otitis Externa

• Bacteria, fungal, or viral infection
• Water in the ear from swimming or poor drainage
• Scratch or cut in the canal, digital trauma
• Chemicals like shampoo, hairspray or gel, makeup or creams
• Sweat and warm weather
• Patients with eczema or psoriasis
• Repeat trauma from foreign objects, like syringes to clear wax
• Inner ear infection or otitis media

Ear wick after expansion. Photo by M. Roberts

The Approach

Insertion of an ear wick for acute otitis externa.

The Pause

Consider prior episodes and treatments, and complete the best ear exam possible.

The Procedure

• Ensure the canal is as dry as possible. Remove any foreign material.
• Obtain two or three ear wicks.
• Insert a single dry, condensed wick into the canal, gently pushing it through the inflamed walls. The wick should be inserted as far in as possible so it is not sticking out.
• Once the wick is inserted, put ear drops directly over the wick to expand it.
• Give the patient a few ear wicks to take home, and instructions how to use them.
• Place ear drops to saturate the wick three to four times a day for five to seven days.
• Most topical preparations should be administered three to four times daily. Topical fluoroquinolones can be given two times daily.
• Ensure that the patient tilts her head to the opposite shoulder while instilling drops.
• The wick allows the medication to stick around so having the patient lay on her side for three to five minutes isn't required.

The Drops

Topical therapy is an effective approach to treating otitis externa and has few side effects. The choice of drops typically depends on what is available and affordable or covered by the patient's insurance. This is worth noting because combination drops are often more expensive and harder to obtain. Interestingly enough, when prescribing dual antibiotic and glucocorticoid drops, writing for two separate concentrations is cheaper. A prescription for Ciprodex, the combined medication, is more expensive than one for ciprofloxacin ear drops and one for dexamethasone ear drops.

Instill three drops of each into the ear for each dosing. Remember that ophthalmic drops of the quinolone family, such as Cipro, can be used in the ear. The same goes for ophthalmic glucocorticoids. Often, pharmacists will call the department and suggest this substitution because it is more cost-effective. One systematic review found no significant difference in cure rates between antibiotic and antibiotic/glucocorticoid preparations nor between quinolone and nonquinolone antibiotics for otitis externa. (Otolaryngol Head Neck Surg. 2006;134[4 Suppl]:S24.) Another study revealed that adding steroids may be of benefit. (Adv Ther. 2007 May;24[3]:671.)

If you are considering bacterial coverage, consider all possible offending parties, which include but are not limited to Staphylococcus, Streptococcus, Pseudomonas aeruginosa, and Escherichia coli, with the most common pathogens being S. aureus and P. aeruginosa. Ofloxacin and ciprofloxacin will provide excellent coverage against these pathogens.

Neomycin-polymyxin B-hydrocortisone (Cortisporin Otic Suspension) can also treat otitis externa. Adding topical steroids to your treatment plan may help treat inflammation, edema, and pain. (Adv Ther. 2007 May;24[3]:671.) If pruritis is severe or the patient has had success with glucocorticoid drops in the past, consider adding dexamethasone to the treatment plan.

Additional antibiotic choices include tobramycin and gentamicin, which are also effective against S. aureus and P. aeruginosa, but one should be concerned about ototoxicity when using these products. These two medications are not routinely recommended, and should only be considered if a patient has a true allergy to cipro or neomycin. If a patient has a true allergy to oral fluoroquinolones, there is a possibility that topical treatment would cause an allergic reaction. It has been noted that allergic contact dermatitis has been notoriously associated with neomycin when used for prolonged courses. (Clin Otolaryngol Allied Sci. 1995;20[4]:326.)

Patients with ear pain should also be managed with oral NSAIDs; those with intense pain associated with severe disease may require opioid analgesics on rare occasions. Acetaminophen and NSAIDs combined may provide relief similar to opioid analgesic. (JAMA. 2017;318[17]:1661; https://bit.ly/2xIJzmB; Evidence-Based Practice. 2020;23[2]:6; https://bit.ly/2L9ue1v.)

Watch a video of this procedure.

Cautions

• Some patients have difficulty using ear wicks or the medications. Patients could have an allergy to the antibiotic drops used or issues with medication preservatives. This may cause the ear to itch more and worsen the situation.
• Consider fungal infection if the patient has chronic otitis externa. Otomycosis can be a difficult fungal condition to treat and requires close ENT follow-up.
• A common cause of failure for topical treatment is underdosing.
• Periauricular cellulitis without evidence of deep tissue infection is generally treated with oral antibiotics.
• Malignant (necrotizing) external otitis is a severe, potentially fatal complication of acute bacterial external otitis, often seen in diabetics. This infection can spread to the soft tissue, cartridge, and skull. These patients need oral and topical fluroquinolones and most likely admission to the hospital with emergent ENT consultation.

Jim Weighs In:

• If you don't have an ear wick, you can instead fill the ear canal with cotton and put the drops on the cotton.
• Tell the patient it might be helpful to have someone else put the drops in the canal because it can be difficult to do that without looking.
• There have been reports of tendon inflammation and rupture with systemic fluoroquinolones. The literature on topical use is limited. Caution the patient about this.
• Do not use alcohol or acetic acid to clean the ear until the tympanic membrane (TM) can be visualized. If there is a TM perforation, acidifying solutions can be particularly irritating to the mucosa of the middle ear.

Martha Weighs In:

• Don't push the wick in so far that you can't see it, and always look for an underlying ruptured tympanic membrane.
• The only safe drop to use on a ruptured TM is cipro or Ciprodex.
• Otomycosis can be treated in the ED but can be time-consuming and is rarely an emergency. Chat with an ENT. The key is a clean and dry ear. Antifungal ear drops such as clotrimazole and fluconazole are needed to treat otomycosis. Acetic acid is another common treatment. Usually, a 2% solution of these ear drops is used several times a day for about a week.
• We really love this Wiley Online reference that summarizes otitis externa and its causes and provides suggestions for treatments based on nefarious underlying diseases and disorders. It also talks at length about drops and how you may want to choose. (J Small Anim Pract. 2016;57[12]:668; https://bit.ly/2L5Mwkn.)

Medication	Information
Ofloxacin (Floxin)	Directions: Instill five drops (0.25 mL) into the affected ear twice daily for seven days. Solution: 0.3%, 5 mL bottle, $30.86-$34.30 Generic: 0.3%, 5 mL or 10 mL bottles, <$30
Ciprofloxacin (Cetraxal, Otiprio)	Directions: Instill four to five drops (0.25 mL) into the affected ear twice daily for seven days.   Solution 0.2%: Instill 0.25 mL (0.5 mg) solution (content of one single-dose container) into the affected ear twice daily for seven days.   Suspension 6%: Instill 0.2 mL (12 mg) suspension into the affected ear as a single dose. Solution (Cetraxal Otic) 0.2% (each): $46.37.   Solution (Ciprofloxacin HCl Otic) 0.2% (each): $8.53.   Suspension (Otiprio Intratympanic) 6% (per mL): $339.84.
Ciprodex (combined cipro and glucocorticoid)	Directions: Instill four drops into affected ear(s) twice daily for seven days.   Suspension, ciprofloxacin 0.3% and dexamethasone 0.1% (7.5 mL).   Suspension (Ciprodex Otic) 0.3-0.1% (per mL): $39.85.
Neomycin-polymyxin B-hydrocortisone (Cortisporin Otic suspension, Cortisporin, Coly-Mycin, Pediotic)	Directions: Instill four drops three to four times daily for seven days; note that otic suspension is the preferred preparation.   Solution or suspension: Generic: neomycin 3.5 mg, polymyxin B 10,000 units and hydrocortisone 10 mg per 1 mL (10 mL).   Solution (Neomycin-Polymyxin-HC Otic) 1% (per mL): $10.07, 3.5-10000-1 (per mL): $10.49.   Suspension (Neomycin-Polymyxin-HC Otic) 3.5-10000-1 (per mL): $10.07-$10.49.
Dexamethasone + glucocorticoid	For otic use: 0.1% ophthalmic solution, topical: Initially, instill three to four drops into the aural canal two to three times a day; reduce dose gradually once a favorable response is obtained. Alternately, you may pack the aural canal with a gauze wick saturated with the solution; remove from the ear after 12 to 24 hours. Repeat as necessary. Solution (dexamethasone sodium phosphate ophthalmic, which can be used as otic) 0.1% (per mL): $12.94. Suspension (Dexycu Intraocular, which can be used as otic) 9% (per 0.5 mL): $714.00.   Suspension (Maxidex Ophthalmic, which can be used as otic) 0.1% (per mL): $18.10.

Source: External Otitis: Treatment. UpToDate, June 14, 2019; https://bit.ly/35FfCAy (subscription required).

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Posted by James R. Roberts, MD & Martha Roberts, ACNP, PNP at 8:19 AM Tags: ear wick, otitis externa, swelling, irritation, pruritis, ear canal, dual antibiotic and glucocorticoid drop, Ciprodex, quinolone, ofloxacin, ciprofloxacin, neomycin-polymyxin B-hydrocortisone, dexamethasone, ruptured tympanic membrane, otomycosis

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Some error has occurred while processing your request. Please try after some time. James R. Roberts, MD & Martha Roberts, ACNP, PNP

James R. Roberts, MD, is the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine at the Drexel University College of Medicine, both in Philadelphia. He is also the chairman of the editorial board of Emergency Medicine News, and has written InFocus for more than 25 years.

Martha Roberts, ACNP, PNP, is the lead nurse practitioner and the director of associate provider education and training for emergency and urgent care at Southwestern Vermont Medical Center, Dartmouth-Hitchcock, and adjunct faculty at Marymount University, Malek School of Health Professions, and Dr. Roberts’ daughter.

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