Confused about what to do with ear pus?

-Let’s discuss the evidence and our otitis externa study.

Introduction

Objectives Authors

Dr Caitlin Chidlow

Dr John van Bockxmeer, FACRRM/DEM, DMO Hedland Health Campus

No conflicts of interest to disclose, no funding for project

Research Setting

Pilbara remote Western Australia 1,640km from Perth/ 2,410km to Darwin/ 1,382km to

Bali Region:

65,859 pop’n 50,587,994ha (6.6% Aus) 12% ATSI 38.3% born o/s 2.5% unemployment 66.8% post school qualifications Construction, mining, agriculture, transport

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15

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25

30

Australian Bureau of Statistics, 2015, Australian Social Trends, viewed 5/9/2017, http://stat.abs.gov.au/itt/r.jsp?RegionSummary&region=50806&dataset=ABS_REGIONAL_ASGS&geoconcept=REGION&datasetASGS=ABS_REGIONAL_ASGS&datasetLGA=ABS_NRP9_LGA&regionLGA=REGION&regionASGS=REGION

Hedland Health Campus Regional resource centre for

Pilbara, 77 bed Pop’n 16k between South & Port

15% ATSI

ED, gen surg, physician, anaesthetist, paed, OGBYN 22,000 ED px/yr

25.2% paediatric

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2000

4000

6000

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12000

1 2 3 4 5

Triage CategoryPresentation

Frequency

Otitis Externa

What is it? Inflammatory condition of external ear Characterised by pain. Patients may also have

itch, discharge, a feeling of fullness or hearing loss Acute diffuse otitis externa generally presents as a

superficial bacterial infection of the canal May also be fungal

Risk Factors

Also known as “Swimmer’s Ear” due to association with water activities

Common in warmer climates Increased in areas with higher humidity and more

water exposure from swimming Compromised skin barrier and changes to pH also

increases risk

Significance and Diagnostic Issues

Swabs may take several days to show result, longer if taken outside of hospital with micro facilities

Around 1% of presentations to ED each year Mobile population, many FIFO workers, people

visiting from remote communities, tourists passing through

Lots of differing guidelines

Research

Stimulus for research, cases & disease burden ‘What to do with ear pus??’

Objectives: Demographic data & representation

Overview of current practices and alignment with guidelines

Microbiology

Investigate seasonal trends

Research Method

15 month retrospective audit extract by Dx All patients px to HHC ED 1/12/15 through 1/4/17

Routine clinical care and data

Extracted from webPAS/ultra

Excel analysis

Ethics approval WACHS & WAAHEC

Results- Demographics 236 cases of otitis externa (1% Px to ED)

301 cases otitis media Higher proportional ATSI disease burden Marked male predominance Bimodal peak aged 5-10 & 45-50 years

42%

58%

ATSI Non- ATSI

61%

39%

Male Female

5%

11%

7% 8% 9% 7%

9% 8% 9% 12%

4% 3% 5%

1% 1% 0%

0-5 5-10 10-15 15-20 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 65-70 70-75 75+

Age Distribution % Cases

Results- Management & Confounders

13% referred to ENT 11% swab rate 17% representation, of which 50% due to

pseudomonas 17% wick insertion

28%

72%

Recent Swimming Yes NoSmoker

6% Non

Smoker 12%

Not Recorded

82%

Smoking Status

10%

3%

1%

86%

Otitis Media

Perforation

Grommets

None

Concurrent Ear Pathology

Results- Microbiology Small sample size n=26 Bacterial infections treated

correctly 34% of the time

7% 3%

4%

15%

11% 48%

4% 4% 4%

Organisms

Aspergillus

Haemophilis

MSSA

Multiple

No growth

Pseudomonas

Staph aureus

Strep

Blank

51%

6.50% 14% 1%

53%

Topical Therapy Used

Amoxicillin

Amoxicillinwith

ClavulanicAcid

Cephalexin

Ciprofloxacin

Flucloxacillin None

Series1 5.30% 15% 7.70% 0.50% 1.90% 69.70%

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%

Oral Antibiotic Use

Results - Representations

Representations -28 patients represented a total of 38 times -13 initially given Dex/Framycetin/Gramicidin -7 Ciprofloxacin -6 Kenacomb -2 Unspecified

12, 45%

7, 26%

6, 22%

2, 7%

Initial Topical Therapy

SofradexCiproKenacombUnspecified

Results - Climate

Large variation in number of presentations each month

19 15 13

6 6

14 13 9 8 6

12 14 16

26 25

34

Num

ber o

f Pre

sent

atio

ns

Month

Presentations by Month

Results- Climate

Strong positive correlation (0.790, p <0.01) between monthly rainfall and monthly otitis externa presentations to ED.

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10

20

30

40

0 100 200 300 400Num

ber o

f Pre

sent

atio

ns

Total Monthly Rainfall

RAINFALL

Results - Climate

Moderate association (0.54, p <0.05) with higher minimum temperatures and increased otitis externa presentation rates.

Association between maximum temperature and presentation rate not significant (0.200, p-value 0.457)

Guidelines & Adherence

We reviewed the most recent guidelines and systematic reviews on management of otitis externa including; Cochrane Collaboration 2010 review BMJ Best Practice Guidelines (UK) 2017 SAGE Clinical Practice Guidelines (USA) 2014

(American Academy of Otolaryngology) Australian Doctor 2007 Kids Health WA Guidelines 2013 Royal Children’s Hospital Guidelines 2009 Therapeutic Guidelines Australia 2014 Kimberley Aboriginal Medical Services 2014

Consensus Guidelines

Consensus no role for oral antibiotics in first-line management of uncomplicated AOE in immune competent patients

Avoid ototoxic drops in patients with perforations Simple oral analgesics first line for pain management Fungal infections should be cleaned

Both children’s hospitals recommend keeping ears

dry by avoiding swimming, ear plugs when showering to prevent further infections

Conflicting Guidelines

Antimicrobials SAGE and BMJ recommend quinolones over other drops KAMS recommended Cipro Therapeutic guidelines, RCH and Kids Health WA recommended

Dexamethasone/Framycetin/Gramicidin first-line Cipro HC only available on PBS for selected groups Aural Toilet KAMS recommended betadine irrigation and tissue spears Therapeutic guidelines recommended suction but said to avoid water RCH recommended ear toilet Kids Health WA recommended saline irrigation if no perforation present

Conflicting Guidelines

Fungal Infections Australian guidelines recommended anti-fungal

therapy first line whereas several international guidelines recommended acetic acid first line

Cochrane review showed acetic acid slightly less effective compared with other topical treatments for both bacterial and fungal infections

Topical Analgesics SAGE and Kids Health WA recommended the use of

topical analgesia if no perforation Other guidelines recommended avoiding topical

analgesics as they may limit effectiveness of antimicrobials

Conflicting Guidelines

Swabs Kids Health WA said swabs unhelpful RCH said swab everyone with discharge KAMS recommended taking both bacterial and

fungal swabs for everyone Wicks Nearly all guidelines recommended insertion of

ear wicks if canal obstructed or oedematous 2010 Cochrane review showed poor evidence

regarding benefit of ear wicks

How Do We Compare?

Dexamethasone/Framycetin/Gramicidin used in 45% of patients, Cipro or Cipro HC in 28%, Kenacomb in 12%

Kenacomb used for all fungal infections, no ascetic acid used.

11% of patients swabbed. Ear wicks documented in 16% of presentations.

Conclusions & Recommendations

No clear consensus guidelines Need for more region specific guidelines? Larger study to determine benefits of swabs to

guide therapy?

Further research Why is rainfall associated with more frequent otitis

externa presentations - ? More places to swim after heavy rainfall?

Further data needed to examine relationship between smoking status and otitis externa

Need to examine hearing protection as a cause of otitis externa

Recommendations

No need to swab patients If represent then treat for pseudomonas and take

fungal and bacterial swabs As a first line follow eTG guidelines and use

Dexamethasone/Framycetin/Gramicidin

Only use wicks if canals are really narrow and you are comfortable inserting them

Recommendations

In areas with high minimum temperatures and rainfall educate patients on risks of otitis externa and ear hygiene

Ciprofloxacin drops first line in Aboriginal children

Reinforce the need for OTC analgesia

Reinforce ear hygiene to patients, especially if fungal infections

Questions ?

Acknowledgements

We would like to formally acknowledge the Kariyarra People, traditional owners of the Port Hedland area, Hedland Health Campus Emergency Department, Wirraka Maya Health Service, WA Country Health Service and the WA Aboriginal Health Ethics Committee .

We would like to thank David Bath for his contribution to statistics and Dr Sarah Prunty for her guidance regarding current guidelines.

References

1. Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA, et al. Clinical Practice Guideline. Otolaryngology–Head and Neck Surgery. 2014;150(2):161-8.

2. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database of Systematic Reviews. 2010(1).

3. Taplin MA. External Ear Conditions. Australian Doctor. 2007 April:25-32.

4. Cheffins T, Heal C, Rudolphy S, Evans R, Vietch C. Acute Otitis Externa – Management by GPs in North Queensland. Australian Family Physician. 2009 April: 262-266

5. Otitis Externa. Therapeutic Guidelines. 2014 6. Acute Otitis Externa. BMJ Best Practice. 2017 7. Coates H. Ear drops and ototoxicity. Australian Prescriber.

Issues. 2008:1.