Drug treatment of ear, nose and oropharynx

Chapter 24 Drug treatment of ear, nose and oropharynx



CHAPTER CONTENTS


Introduction 474

Drug treatment of disorders of the ear 474
Anatomy and physiology 474

Common conditions 474

Administration of ear preparations 477

Drug treatment of disorders of the nose 478
Anatomy and physiology 478

Nasal administration of drugs 478

Common conditions and their treatment 478

Administration of nose preparations 480

Drug treatment of oropharyngeal disorders 480
Anatomy and physiology 480

Common conditions and their treatment 480

Preparations used in general care of the mouth 483

Oral hygiene 484

Care of the mouth in special situations 485
Reduced salivary flow 485

Lowered resistance to infection 485

Post tonsillectomy 485

Postradiation inflammation of the throat 485

Self-assessment questions 486


KEY OBJECTIVES


After reading this chapter, you should be able to:


• describe the presentation of acute otitis media and discuss treatment options

• describe how to administer ear drops

• discuss the treatment of fungal infections of the oropharynx

• explain the importance of oral hygiene as part of patient care

• describe how to administer nasal drops.


INTRODUCTION


Disorders of the ear, nose and oropharynx vary greatly in their implications for patients. Unless effectively treated, these conditions can at best cause a great deal of misery for patients and at worst may be life-threatening. Underlying causes of the patient’s condition must be identified and dealt with, if necessary by a combination of local and systemic therapy and surgery. Some local preparations may be helpful but over-reliance should not be placed on these. Simple remedies should always be considered. The nurse’s role in providing effective aural, nasal and oral care is pivotal. Self-care is to be encouraged through teaching.



DRUG TREATMENT OF DISORDERS OF THE EAR



ANATOMY AND PHYSIOLOGY


There are three main parts to the ear (Fig. 24.1):


• outer ear – pinna (auricle) and external auditory canal

• middle ear – tympanic membrane and ossicles

• inner ear – cochlea and vestibular labyrinth.

image

Fig. 24.1 The ear.


(From Waugh A, Grant A 2001 Ross and Wilson anatomy and physiology in health and illness, 9th edn. Churchill Livingstone, Edinburgh. With permission of Elsevier.)


Sound waves reaching the pinna are channelled through the external auditory canal to the tympanic membrane (eardrum), which vibrates in response. These vibrations are transmitted through the ossicles to the cochlea, which converts them into impulses for transmission by the auditory nerve to the brain. The middle ear connects to the throat via the eustachian tube.



COMMON CONDITIONS


Each part of the ear may be affected by disease. The outer ear may be affected by skin conditions such as eczema, dermatitis and furuncles (boils), with itching and pain as the presenting symptoms. Inflammation of the external auditory canal/pinna is known as otitis externa. Wax (cerumen), secreted by cells in the external auditory canal, may cause some loss of hearing when production is excessive. The ciliated epithelial cells that line the middle ear secrete mucus. Otitis media with effusion (‘glue ear’) is a condition in which the middle ear becomes congested with mucus. When the mucosa becomes infected, resulting in pus formation, the resulting painful condition is known as acute otitis media. Occasionally, pressure build-up will cause the tympanic membrane to rupture; this results in pressure release and subsidence of pain. Repeated episodes of infection with recurrent discharge of pus may lead to persistent rupturing of the tympanic membrane and the condition known as chronic otitis media. Conditions affecting the inner ear are dealt with in Chapter 14. In the investigation of all significant ear problems, suitable hearing tests should be carried out. In addition, it is vitally important to exclude serious underlying conditions.


The main features and treatment of otitis externa and the various forms of otitis media are outlined in Table 24.1.


Table 24.1 Treatment of common forms of otitis



























Condition Main features Treatment
Otitis externa Inflammation of meatal skin, associated with infection and/or eczema. Itching and pain without hearing loss. Predisposing factors include loss of self-cleaning epithelium. Overenthusiastic cleaning of the ears (e.g. cotton buds, syringing) may be a contributing factor. Exclude chronic otitis media before initiating treatment. Aural toilet, astringent ear drops (e.g. aluminium acetate, antimicrobial agents) may be indicated depending on swab/culture. If eczematous condition is present, topical steroids may be required.
Otitis media Hearing impairment, earache – due to inflammation or infection. See otitis media with effusion, acute otitis media, chronic otitis media
Otitis media with effusion Hearing impairment, earache. As with acute otitis media, worse in water. Observation, pain relief and antibiotics, simple analgesics for pain in acute conditions. Surgery required in order to achieve resolution of the condition.
Acute otitis media Earache, discharge, hearing impairment, tympanic membrane inflamed, fever, lymphadenopathy. Occurs from first year of life onwards. Referral for specialist advice is needed in cases of acute pain or neurological involvement. Local treatment with antibiotic ear drops is of no value. The aim is to avoid progression to chronic otitis media. Oral antimicrobial agents are widely used. A pragmatic approach is adopted, choice of antibiotic depending on pathogen present. Oral amoxicillin is the first choice. Antibiotic resistance is a growing problem. Prophylactic antibiotics may be needed if acute otitis media is recurrent.
Chronic otitis media History of childhood ear problems, recurrent discharge, hearing problems. If neurological symptoms occur (e.g. vertigo), urgent referral to specialist. The condition occurs in approximately 5% of the adult UK population. It should be noted that there are linkages between the above conditions. Aural toilet to remove debris (e.g. keratin and necrotic bone). Antibiotic treatment, depending on sensitivity of organisms.


TREATMENT OF OTITIS EXTERNA


A furuncle is an infected hair follicle, usually caused by Staphylococcus aureus. This can be very painful, especially when the pinna is moved. Applying a hot flannel to the infected ear and the use of simple analgesics may be sufficient, but oral antibiotics may be necessary if symptoms are very severe.


In acute otitis externa, the ear appears red, swollen or scaly and it is important to exclude underlying otitis media before treatment is started. Acetic acid ear drops act as both antifungal and antibacterial agent in the external ear canal; they can be purchased over the counter for mild otitis media and are less likely to cause superinfection. Aluminium acetate ear drops have astringent properties and may be used to reduce inflammation. Topical corticosteroids such as betamethasone or prednisolone can also be used if infection is not present. When infection is suspected, a topical anti-infective agent that is not used systemically can be used (e.g. neomycin or clioquinol).



TREATMENT OF OTITIS MEDIA


Acute otitis media often follows an upper respiratory tract infection and can be viral or bacterial. Most, 75% (Scottish Intercollegiate Guidelines Network 2003), acute otitis media occurs in children under 10 years of age. Otitis media with effusion, or glue ear, is a chronic inflammation of the middle ear accompanied by accumulation of fluid. It occurs in 10% of children and in 90% of children with cleft palates. Untreated or resistant glue can lead to some forms of chronic otitis media. Key elements of treatment of all forms of otitis media are aural toilet, exclusion of complicating factors and the need to ensure that an acute condition does not become chronic. Most uncomplicated cases resolve without the need for antibacterial treatment, and use of simple analgesia such as paracetamol is effective. The Committee on Safety of Medicines has stated that treatment with a topical aminoglycoside antibiotic is contraindicated in those patients with a perforated tympanic membrane. However, some specialists do use these cautiously in the presence of perforation in patients with otitis media when other measures have failed. The risk of ototoxicity arising from the infected pus is greater than the risk of side effects from the antibiotic.


Although antibiotics are widely used to treat acute otitis media, the role of these agents has been questioned. The evidence to show that any improved outcome is achieved with antibiotic therapy is sparse. Infecting organisms are commonly Streptococcus pneumoniae, Haemophilus influenzae, staphylococci and streptococci. In children without systemic symptoms, oral amoxicillin or erythromycin may be started if there is no improvement within 72 h, or earlier if deterioration occurs. Treatment is usually only for 5 days.



REMOVAL OF EARWAX


Earwax is a combination of cerumen, sebum, dead cells, sweat, hair and dust. In most circumstances, it is not necessary to clean the ear canals. However, sometimes earwax can build up and impede the passage of sound. It is sometimes possible to loosen small amounts of earwax using wax-softening drops alone. Syringing with warm water using an ear syringe or an electronic pulsed water unit (Box 24.1) is carried out to remove plugs of wax that block the ear causing discomfort and deafness, or when closer inspection of the eardrum is required. Syringing is preceded for several days by a course of wax-softening drops such as olive or almond oil (care must be taken for those with nut allergy) or sodium bicarbonate ear drops. Some proprietary preparations contain an organic solvent that may cause sensitisation and should be used only when oil or sodium bicarbonate ear drops have failed. Because of the potential danger of perforating the tympanic membrane, the ear is examined by a doctor or practice nurse using an otoscope before syringing takes place.



Box 24.1 Syringing the ear



The medicine



• Tap water at body temperature (38°C)


The environment



• Usually GP’s clinic or surgery by practice or district nurse


The nurse and the patient



• Hand hygiene before and after procedure

• Patient given clear explanation of what is involved

• Patient informed that there may be some discomfort

• Privacy, warmth, comfort

• Patient seated in upright chair with towel over appropriate shoulder

• Patient asked to hold receiver against neck just below ear to be treated


Technique



• Syringe filled with water or pulsed water unit primed and air expelled

• Pinna pulled up and back

• Fluid directed along roof of auditory canal without undue force but at a steady rate

• Content of returned fluid observed

• Procedure repeated until all wax removed

• Meatus inspected periodically using otoscope to check that wax has been removed and ear has not been damaged

• Patient understanding checked, as hearing may be affected

• External auditory meatus gently but thoroughly mopped dry


Hazards



• Infection of the middle ear, resulting from rupture of the tympanic membrane

• Otitis externa


ADMINISTRATION OF EAR PREPARATIONS


As always, the standard procedure for prescribing and recording medications must be followed. Hands should be washed before and after each procedure, and each patient should have a separate medicine container. When checking preparations against the prescription, special note should be made of the strength of the medication and, for example, the number of drops to be instilled and whether both ears are to be treated. Explanation of the procedure is important in order to gain the patient’s cooperation so that the medication is allowed to take maximum effect with minimal discomfort. Correct positioning of the patient helps to minimise discomfort and ensure penetration of the medication to the part where it is intended to take effect. Before instilling drops, instructions may be given by the doctor to mop the ear canal using a cotton-tipped applicator for better penetration of the medication. Ear drops are solutions or suspensions of active ingredients in water, propylene glycol or other suitable vehicle. Ear drops should be used in the temperature range between room and body temperature. If ear drops are instilled from a bottle recently stored in a refrigerator, they may cause a mild vertigo.


Patients may be helped to feel more secure through-out the procedure if they are given an absorbent tissue to hold. For patients receiving ear drops who are unable to maintain the required position, a wisp of cotton wool may be gently placed in the ear canal to ensure that the drops remain in contact with the epithelium. The prescribed volume of ear drops may range from two to four drops. Glass droppers are rarely used, but if one is used it is important to check the top of the dropper each time to ensure that it is not chipped or cracked. Most ear drops come in plastic bottles with an integrated dropper attached. Box 24.2 details the step by step process for instillation of ear drops.



Box 24.2 Instillation of ear drops



Documentation



• Standard prescribing and recording sheet


The medicine



• Prescribed ear drops

• Separate bottle for each patient

• At room temperature, at least


The nurse and the patient



• Patient identified

• Patient given explanation

• Patient assisted as necessary into position either sitting with head tilted to one side or lying on side with ear to be treated uppermost

• Patient’s clothing protected

• Patient made comfortable


Technique



• If instructed, external auditory meatus gently mopped with cotton-tipped applicator

• Hand hygiene before and after actual instillation of drops

• Bottle shaken if it contains a suspension and required amount drawn into dropper (if ear drops come with separate dropper)

• Cartilaginous part of pinna gently pulled up and back (for a child, down and back)

• Drops instilled in external canal without allowing dropper or top of bottle to come into contact with ear

• Gentle massage applied over tragus to help work in drops

• Patient encouraged to maintain position for several minutes to allow drops to reach eardrum

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May 13, 2017 | Posted by in NURSING | Comments Off on Drug treatment of ear, nose and oropharynx

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