16.16 Otitis Externa

Otitis externa is inflammation of the external auditory canal that sometimes spreads to the outer ear. See Figure 16.22^[1] for the location of the external auditory canal. This condition is commonly referred to as swimmer’s ear because it is associated with retained water in the ear resulting from swimming. It is usually caused by a bacterial infection, but it is also linked to allergies, psoriasis, eczema, and fungal infections. Risk factors, in addition to swimming, are the use of external devices like ear plugs, increased humidity, immunodeficiency, and narrow or obstructed ear canals. Acute otitis externa lasts less than six weeks, whereas chronic forms last over three months. Although this condition can occur in any age group, it is most commonly seen in those between 7 and 14 years of age.^[2]

A potential complication of otitis externa that can occur in immunocompromised clients or clients with diabetes is malignant otitis externa. Malignant otitis externa refers to infection that spreads to the temporal bone and is typically caused by Pseudomonas aeruginosa. Early diagnosis is crucial because this complication has a high mortality rate; therefore, it should be suspected in clients at risk who have otitis externa and a fever and who do not respond to treatment.^[3]

Pathophysiology

The external auditory canal contains glands that produce cerumen, also known as earwax. Cerumen not only protects the external auditory canal but also creates an acidic environment that inhibits the growth of pathogens. When this environment is disrupted, inflammation leads to loss of cerumen, damages the epithelium of the canal, and causes moisture retention in this area. Ultimately, this leads to an increase in the pH of the external auditory canal and the promotion of bacterial growth.^[4]

Assessment (Recognizing Cues)

Physical Exam

When assessing a client with potential otitis externa, the external and internal portions of the ear should be examined for redness and edema. Debris may also be present. Clients may have symptoms of mild to severe ear pain, itching, ear discharge, a sense of fullness in the ear, and potential hearing loss. In severe cases, the entire external auditory canal becomes occluded due to edema, and the client may have a fever and enlarged lymph nodes. It is possible for the client to have otitis media at the same time as otitis externa, so the tympanic membrane should be assessed as well.^[5]

Potential complications of otitis externa are hearing loss, permanent narrowing of the external auditory canal, and progression of the infection to nearby structures. Malignant otitis externa can occur when the initial infection spreads to the temporal bone, leading to osteomyelitis. Early diagnosis of this complication is essential due to its high mortality rate.^[6]

Common Laboratory and Diagnostic Tests

A diagnosis of otitis externa is made clinically. Cultures of the ear canal or further testing may be performed for recurrent cases or for clients with an immunodeficiency.^[7]

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with otitis externa include symptom management and prevention of complications. Nursing diagnoses for clients with otitis externa are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment.

Possible nursing diagnoses for clients with otitis externa are as follows:

• Acute pain r/t disease process
• Disturbed sensory perception r/t disease process
• Risk for injury r/t complication development

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, achievable, relevant, and timebound (SMART) within a set time frame based on the application of appropriate nursing interventions. Sample expected outcomes for clients with otitis externa include the following:

• The client will exhibit a reduction in pain using a numeric scale, FACES, or FLACC, within one hour of treatment.
• The client will exhibit a reduction in the symptoms of otitis externa within one week.
• The client will demonstrate normal hearing after the illness has resolved.

Interventions (Generate Solutions & Take Action)

Medical Interventions

Medical interventions for otitis externa consist of antibiotic ear drops and pain management. Acetaminophen or NSAIDs can be used for mild to moderate pain, but more severe pain may require the use of opioid medications. Antibiotic ear drops may be combined with steroids to reduce inflammation and improve pain relief. If edema is severe, an ear wick made of gauze may be placed in the external auditory canal to facilitate delivery of ear drops. In some cases of otitis externa, lavage or washing out of the external auditory canal may be performed, but this is not routinely done in primary care offices. It should be avoided in diabetic clients, as it can promote the development of malignant otitis externa. Oral antibiotics are prescribed for clients with diabetes, immunodeficiency, accompanying otitis media, or malignant otitis externa. Referrals are made to an ear, nose, and throat provider for clients with severe or treatment-resistant cases of otitis externa or if there is suspicion for malignant otitis externa.^[8]

Nursing Interventions

Registered nurses develop interventions based on the expected outcomes of the client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client.

When caring for a client with otitis externa, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching as described in the following subsections.^[9],[10]

Nursing Assessments

• In clients with recurrent otitis externa, assess for potential hearing loss.
• Assess for worsening symptoms such as increasing pain or no improvement despite treatment, as this can indicate a complication is occurring.

Nursing Actions

• Ensure a referral is made to an ear, nose, and throat provider when appropriate.
• Administer antibiotics and pain medications per provider order.

Client Teaching

• Educate the client and their caregivers on ear drop administration. The client should lie on their unaffected side, apply the drops into the ear canal, and remain lying on that side for three to five minutes after administration.
• Educate the client and their caregivers on the need to avoid swimming and other forms of water exposure until the infection clears.
• Teach the client and their family on methods to prevent otitis externa by promoting water drainage from the ears after water exposure. This can be done by tilting the head from side to side, drying the ears with a towel, or using a hairdryer on a low setting on the ear canal.

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.