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NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide).
Some of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.
Otitis externa is inflammation, with or without infection, of the external ear canal. Many cases recover after thorough cleansing of the external ear canal by suction or dry mopping.
Caution is advised to ensure that the repeated episodes of irritation and discharge represent genuine otitis externa, and not an underlying chronic otitis media with perforation.
The most effective method is to introduce a ribbon gauze dressing soaked with corticosteroid ear drops or with an astringent such as aluminium acetate solution.
Ear swabs for culture should be reserved for treatment failures or chronic cases. They may be carried out using a urethral swab (i.e. narrow cotton-tipped swab on a wire, not a 'throat' swab).
When considering specialist referral see: Western Devon CRG: Otitis Externa and South Devon and Torbay CRG: Otitis Externa
Some patients present with frequent otitis externa that may be related to water sports, vigorous ear cleaning or chronic dermatitis. For patients who develop itching, pain or irritation of the ear canals after exposure to water, an acetic acid (vinegar) and alcohol based ear wash can be very effective in avoiding development of infective and more severe otitis externa by immediate use after water has entered the ears.
Indications
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Early brief treatment (as short as 48 hours) of exacerbations of chronic eczematous otitis externa with steroid ear drops may be helpful; however, avoid prolonged use of topical steroids. Microsuction should be considered where there is a build-up of debris or an inadequate response to initial topical treatment.
Indications
Dose
Indications
Dose
Infective otitis externa may be treated with aural antibiotics and anti-inflammatory drops. There are no indications for systemic treatment unless systemic symptoms or local spread leading to oedema, cellulitis and erysipelas. Solutions containing a corticosteroid agent are useful for treating cases with inflammation and eczema.
Consideration should be given to the fact that pseudomonal resistance to aminoglycoside antibiotics is growing.
In view of reports of ototoxicity, manufacturer's contra-indicate treatment with a topical aminoglycoside or polymixins in those with a perforated tympanic membrane (eardrum) or patent grommet.
If infection is present a topical anti-infective agent that is not usually used systemically (e.g. neomycin or clioquinol) may be used, but for about a week as excessive use may result in fungal infections. Fungal infections may be difficult to treat and require specialist referral (Refer to below).
Indications
Dose
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(Combination of dexamethasone 0.1%, neomycin sulphate 0.5% (3,250units/ml), glacial acetic acid 2%)
Indications and dose
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Indications and dose
Notes
Indications and dose
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Indications and dose
Notes
(combination of dexamethasone 0.05%, framycetin sulphate 0.5%, gramicidin 0.005%)
Notes
(combination of triamcinolone acetonide 0.1%, neomycin sulphate 0.25%, gramicidin 0.0025%, nystatin 100,000 units/g)
Fungal external ear infections are not unusual and may be the result of over-use of aural and oral antibiotics. They may be difficult to treat; specialist referral should be considered if treatment with clotrimazole ear drops fails to resolve symptoms.
Indications and dose