Introduction
Acute otitis externa is a common ENT condition encountered in primary care,Reference Rowlands, Devalia, Smith, Hubbard and Dean1 and the most frequent condition referred to ENT emergency clinics.Reference Smyth, Moran, Diver and Hampton2
Guidelines provided by the National Institute for Health and Care Excellence and the American Academy of Otolaryngology—Head and Neck Surgery Foundation provide advice in managing this condition,3,Reference Rosenfeld, Schwartz, Cannon, Roland, Simon and Kumar4 but are not tailored towards secondary care management.
The purpose of this project was two-fold: to design and implement a simplified treatment algorithm to support juniors doctor working in emergency clinics, and to improve the management of otitis externa patients presenting to a busy ENT emergency clinic.
Materials and methods
This quality improvement project was undertaken at a regional referral centre for ENT. Its emergency clinic/treatment room provides a pathway for primary care, the emergency department and surrounding hospitals to refer a patient for rapid review. It is run by junior doctors (at the senior house officer grade), with support of the on-call senior ENT specialist.
The project was reported based on the Standards for Quality Improvement Reporting Excellence 2.0 guidelines. The audit was registered and approved by the centre's audit and clinical research department.
Patient selection
Patients referred to the ENT treatment room between November 2021 and October 2022 with otalgic symptoms or suspected otitis externa were screened. Cases where the diagnosis of otitis externa was clinically confirmed were included and their clinical journey reviewed. Patients who re-presented to the service more than 14 days after their last review were considered to have a new acute presentation of otitis externa.
Data collection and intervention
Baseline data were collected for 16 weeks through a retrospective audit of practice. The first cycle (Cycle 1) introduced the new otitis externa treatment algorithm (Figure 1), with 16 weeks of prospective data collected. The second cycle (Cycle 2) provided additional emphasis on correct topical antibiotic prescribing (Table 1) and water precaution advice after the first audit found these to be areas that required further support.
Otitis externa treatment algorithm (adapted for legibility). The guidelines used to create this algorithm and sources of further information can be found in Rodenfeld et al.Reference Rosenfeld, Schwartz, Cannon, Roland, Simon and Kumar4 and the National Institute for Health and Care Excellence.5 HR = heart rate; BP = blood pressure; TDS = three times a day
Topical antibiotic guide for otitis externa
TDS = three times a day ; BD = twice a day
Statistical analysis
Data were collected and analysed using Excel® (Microsoft, Redmond, WA, USA). Statistical significance was set at a p value of <0.05. Numerical data were compared with a Kruskal–Wallis test, and categorical data were compared witheither a chi-square test or Fisher's exact test.
Results
Overall, 202 cases of otitis externa managed in the treatment room were reviewed (baseline 58 cases vs Cycle 1 57 cases vs Cycle 2 87 cases). The proportion of cases involving female patients was 54.46 per cent, and the mean age was 42.70 years. The patient demographics remained relatively consistent across each cycle and are detailed in Table 2.
Baseline characteristics of the study population
Topical antibiotic prescribing and water precaution advice
The prescriptions and guidance provided to patients across each intervention period are shown in Table 3.
Summary of care delivered to patients with otitis externa in the ENT urgent treatment room
The incidences of topical antibiotic prescriptions being fully detailed in the documentation of treatment room reviews fluctuated, but were noted to be rising following second-cycle intervention (baseline 35.09 per cent vs Cycle 1 29.09 per cent vs Cycle 2 45.78 per cent, p = 0.12). The correct dosing of topical antibiotics increased significantly (baseline 30.00 per cent vs Cycle 1 56.25 per cent vs Cycle 2 72.22 per cent, p = 0.01).
The proportion of cases where water precaution advice was given improved significantly (baseline 44.83 per cent vs Cycle 1 52.63 per cent vs Cycle 2 82.76 per cent, p = <0.01).
Deviation from the recommended treatments specified in the algorithm differed significantly across the implementation cycles (baseline 5.17 per cent vs Cycle 1 7.02 per cent vs Cycle 2 17.24 per cent, p = 0.04). Further analysis showed there was a larger incidence of fungal otitis externa during the second cycle (baseline 3.45 per cent vs Cycle 1 1.75 per cent vs Cycle 2 9.20 per cent, p = 0.26). Non-guideline treatment with clotrimazole showed a generally increasing trend towards Cycle 2 (baseline 3.45 per cent vs Cycle 1 1.75 per cent vs Cycle 2 9.20 per cent, p = 0.15), and non-treatment guideline excluding clotrimazole exhibited a similar pattern (baseline 1.72 per cent vs Cycle 1 5.26 per cent vs Cycle 2 8.05 per cent, p = 0.27). Of the cases who received clotrimazole, only three in the second cycle had aspergillus or yeast grown on their microbiology swab (baseline 0 per cent vs Cycle 1 0 per cent vs Cycle 37.5 per cent).
Review patterns and senior involvement
The number of days between reviews was significantly lower amongst patients with pope wicks inserted by the end of the second cycle (baseline 3.50 vs Cycle 1 3.53 vs Cycle 2 3.00 days, p = 0.01).
The mean number of reviews required to treat each case showed an overall increasing trend (baseline 2.10 vs Cycle 1 2.39 vs Cycle 2 2.47, p = 0.69), with similar patterns in the review numbers amongst patients who required pope wicks (baseline 2.57 vs cycle 1 3.10 vs cycle 2 3.62, p = 0.49).
Instances where the on-call senior ENT specialist had to be involved in a case showed a general pattern of reduction following the interventions (baseline 32.76 per cent vs Cycle 1 28.07 per cent vs Cycle 2 25.29 per cent, p = 0.62).
Admission rates
The proportion of cases requiring in-patient admission for otitis externa was 7.43 per cent across the study period and did not differ significantly across the three cycles (baseline 5.17 per cent vs Cycle 1 5.26 per cent vs Cycle 2 10.34 per cent, p = 0.48). The most common reasons for an admission were either suspicion of necrotising otitis externa (50.00 per cent) or involvement of facial cellulitis (28.57 per cent).
Microbiology results
Culture results in cases where a microbiology swab was taken demonstrated minimal variation and are shown in Table 4. Over half of the swab results grew Pseudomonas aeruginosa (baseline 55.81 per cent vs Cycle 1 68.97 per cent vs Cycle 2 53.45 per cent) and up to almost a third of swabs grew either skin flora or had no growth (baseline 27.91 per cent vs Cycle 1 13.79 per cent vs Cycle 2 31.03 per cent).
Culture results of the cases where a microbiology swab was taken
Discussion
This study has effectively introduced a simplified treatment algorithm of otitis externa management for use by junior doctors running emergency clinics in ENT. Its use has improved documentation, correct antibiotic use and dosing, and reduced senior ENT specialist input, with a trend towards more independent practice. A secondary care otitis externa algorithm is unique within the literature and provides a useful resource for junior doctors in managing this common condition.
The treatment algorithm was designed through departmental discussion and review of the current available guidance from National Institute for Health and Care Excellence and American Academy of Otolaryngology—Head and Neck Surgery Foundation.3,Reference Rosenfeld, Schwartz, Cannon, Roland, Simon and Kumar4 Its utility stems from its provision of a clear pathway for patients to be managed in a secondary and/or tertiary centre with access to microscopy, pope wick insertion and on-site ENT specialist review, thus providing junior ENT doctors and ANPs with guidelines that can better make use of all the available resources to deliver care. Moreover, it advocates leaving 3 or 4 days between reviewing patients, in a bid to reduce unnecessary clinical reviews and give topical therapy the chance to work effectively.
Implementation of the treatment algorithm in conjunction with topical antibiotic guidance was shown to increase the instances in which topical antibiotics are correctly prescribed. The change both drives safer care and improves antibiotic stewardship. The algorithm further acts as a prompt to ensure basic, yet crucial, water precaution advice is given to each patient to prevent prolonged illness and recurrence of otitis externa.
The interventions have further been shown to be a useful educational tool, empowering junior ENT doctors to manage otitis externa independently and reducing the requirement for senior input. Pope wicks indicate more severe disease and the decrease in the number of days between reviews and a general trend towards more reviews within this subgroup likely represents an expected level of caution taken by junior doctors as they work more independently.
Ibrahim et al. reported that introduction of an established protocol for otitis externa alongside education of the larger healthcare team resulted in a reduction in patient follow ups.Reference Ibrahim, Virk, George, Elmiyeh and Singh6 Similarly, other groups have noted an increase in discharges after a first review following implementation of an otitis externa pathway.Reference Evans, Henderson and Gillett7 Whilst our results showed a general trend towards increasing reviews, the focus of our study was also different in that its primary objective was to promote independent practice amongst more junior doctors by designing more complete guidance.
In comparison to both the otitis externa flow chart by the American Academy of Otolaryngology—Head and Neck Surgery FoundationReference Rosenfeld, Schwartz, Cannon, Roland, Simon and Kumar4 and that published by Ibrahim et al.,Reference Ibrahim, Virk, George, Elmiyeh and Singh6 our guidelines provide a more detailed overview, including when to escalate to a senior clinical member, and an emphasis on providing water precaution advice. The latter is very important because a recent study reported that only 39 per cent of patients referred into an ENT tertiary centre had received water precaution advice, and thus missed the opportunity for a cost-effective and side-effect-free intervention.Reference Mather, Mohammed and Wilson8
• Otitis externa is an extremely common condition presenting to primary care and specialist ENT services, and often managed by junior doctors
• Guidelines to manage the condition exist, but none are tailored towards ENT junior doctors working in emergency clinics
• The treatment algorithm improved documentation and antibiotic prescribing, and reduced the requirement for senior specialist review
• Junior doctors became more independent in managing otitis externa following the introduction of the algorithm
• The algorithm provides a useful framework to follow, allowing inexperienced junior doctors to become more confident in managing otitis externa
A challenging aspect of otitis externa management that remains is the diagnosis and treatment of otomycosis; a modified version of the algorithm that accounts for this condition enables it to help manage the various presentations of otitis externa. Fungal otitis externa is reported to be increasing potentially as a result of the use of broad-spectrum antibiotics.Reference Song, Haberkamp, Patel and Redleaf9 Although hallmarks of its presentation are thick white fluid or black hyphae,Reference Martin, Kerschner and Flanary10 its common symptoms, including serous drainage, erythema and oedema, make it challenging to distinguish from bacterial otitis externa.Reference Song, Haberkamp, Patel and Redleaf9
This difficulty is reflected in the results of the cases managed as otomycosis in our cohort, where either no or only a minority of cases were confirmed to have grown fungus on their microbiology swabs. In addition, the absence of guidance in the treatment algorithm for fungal otitis externa resulted in cases treated with clotrimazole being coded as non-guideline treatment in our dataset.
A rise in presumed otomycosis in our third cycle likely exacerbated natural variation in the use of other non-guideline treatments such as Tri-adcortyl ointment, and resulted in the significant increase in non-guideline management across the cycles. We have devised a modified treatment algorithm to account for this and help manage fungal otitis externa presentations (Figure 2). The addition allows for the algorithm to help manage otitis externa across both bacterial and fungal causes.
Modified otitis externa treatment algorithm accounting for fungal otitis externa. The guidelines used to create this algorithm and sources of further information can be found in Rodenfeld et al.Reference Rosenfeld, Schwartz, Cannon, Roland, Simon and Kumar4 and the National Institute for Health and Care Excellence.5 HR = heart rate; BP = blood pressure; TDS = three times a day
Limitations
The approach to coding cases of acute otitis externa means that patients with multiple presentations who would be more accurately described as suffering from chronic otitis externa are included in the dataset and could skew results.
Conclusion
Our experience shows that implementation of an otitis externa treatment algorithm alongside topical antibiotic guidance advice results in a marked improvement in the treatment of this condition and empowers junior doctors to manage otitis externa effectively. Further incorporation of guidance on managing otomycosis in the modified treatment algorithm enables it to help manage otitis externa across its spectrum of bacterial and fungal causes. Adopting these tools in other centres has the potential to bring about similar benefits and help upskill the ENT workforce.
Competing interests
None declared
