Pharmacy First: Top tips for managing otitis media

CLINICAL UPDATE

The Pharmacy First service in England enables pharmacists to diagnose and treat seven specific conditions, with the aim of reducing current pressures on general practice.

This series of guides assumes that pharmacists are familiar with the clinical pathways and requirements for Pharmacy First. The articles explore some key aspects of each service to support and enhance pharmacists’ knowledge.

Here, GP Dr Toni Hazell offers tips on diagnosing and treating acute otitis media in line with the Pharmacy First service.

 

Otitis media (OM) is caused by inflammation in the middle ear. As with tonsillitis and other respiratory tract infections, it can be caused by common viruses and will often get better on its own. 60% of children with OM will recover within 24 hours without antibiotics, and most will get better within three days.¹ This is therefore another Pharmacy First service where pharmacists may find they need to say ‘no’ to patients and their parents who have come with the expectation of antibiotics.

Here are my top tips on how to assess and manage possible OM in those aged one to 17 years, appropriately and in line with the new Pharmacy First service.

1. Be aware of some rare but significant differentials

Common things are common, and it is an old medical aphorism that when you hear hooves, you should think horses, not zebras.² Around 50–85% of children will have experienced acute OM by the age of three, but you might occasionally see a child who has something more significant wrong with them. The Pharmacy First algorithm suggests that we think about meningitis, mastoiditis, brain abscess, sinus thrombosis and facial nerve paralysis.

To give some idea of how rare these are: I have been a GP for 20 years and I’ve seen only a handful of cases of meningitis and facial nerve paralysis and never seen the other three conditions. From the perspective of a pharmacist, the key point is to be able to recognise the sick patient who needs more care than you can give. The Pharmacy First pathway suggests calculating a NEWS2, an early warning score for sepsis. However, as explained in a previous article in the series, it is important to be aware that this is not validated for use in primary care and you should not rely solely on a score.^3,4

It is more important for pharmacists assessing patients clinically to develop a feeling for when a patient looks unwell, backed up by physiological measurements.  A patient looks sweaty or feels dizzy, is tachycardic or has a low blood pressure should raise your concern. Look for signs of dehydration, such as a dry mouth or skin, sunken eyes, or poor skin turgor – skin which doesn’t bounce back when pinched.⁵ This might be backed up by a history of poor food intake, less urine output than normal, and feeling tired or dizzy.

Specific signs of the five key serious conditions to look out for are outlined in the box (see below). Of particular note, the pathway doesn’t explain what a facial nerve paralysis is – a patient whose facial nerve isn’t working properly won’t be able to raise their eyebrows, smile or close their eyes tightly. These signs are usually found just on one side of the face.

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Box: Suspected acute complications of ear infection

• Meningitis (neck stiffness, photophobia, mottled skin).
• Mastoiditis (pain, soreness, swelling, tenderness behind the affected ear[s]). Note this should not be confused with the much more common post-auricular swollen gland. In mastoiditis the swelling is bony and may push the ear outwards.
• Brain abscess (severe headache, confusion or irritability, muscle weakness).
• Sinus thrombosis (severe headache behind or around the eyes, often with fever/rigors).
• Facial nerve paralysis (usually unilateral, affecting patient’s ability to raise eyebrows, smile or close eyes tightly).

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Any suggestion of a serious diagnosis such as those listed above should prompt you to direct the patient to the emergency department, but be aware of their rarity. Anecdotes from GP practices attached to pharmacies which were early adopters of Pharmacy First include tens of cases of ‘possible mastoiditis’ being sent to the GP each day – if that is happening, your clinical assessment likely needs adjusting.

2. Taking a history is key

Patients love tests. If I had £10 for every patient saying ‘I think I need a scan doctor’, I’d be on an island in the Caribbean by now. But most of the diagnosis, maybe up to 80%,⁶ is made by the history, and the examination adds a significant amount to that: tests aren’t really relevant in the diagnosis of straightforward OM.

Older children can tell you that their ear (usually only one) is painful, or in the case of a pre-verbal child, look for one who is holding, tugging or rubbing their ear.

Context is important too. Is there anything to suggest another reason for a painful ear – were they recently playing with something small enough to be put into the ear, but not retrieved? Have they hit their head, or has their sibling hit them with a toy? Is the pain there all the time, or does it come and go, and does it seem to be getting worse or better over time? Has it ever happened before, and if so did it get better on its own, or need treatment?

Infants might also seem non-specifically unhappy – crying, restless, not feeding or with a temperature. They may have other features of an upper respiratory tract infection, such as a cough or runny nose.

3. Look for a bulging eardrum or sticky discharge

Find someone experienced to teach you how to get parents to hold a wriggling child firmly, so that you can do a quick and efficient ear examination (ideally followed with a sticker of the child’s choice to make them forget their ordeal).

When performing any ear examination it is important to be familiar with what a normal, healthy ear canal and eardrum (tympanic membrane; TM) looks like. The ear canal is skin-coloured and has small hairs, and there may be some yellow-brown ear wax present. A healthy TM is light pinkish-grey or pearly white in colour, translucent and light should reflect off its surface. (see image 1).

 

Image 1. Otoscope view of healthy TM

In an ear with OM the TM will be red, and may be bulging and/or (less commonly) yellow or cloudy (see image 2). The normal light reflex is lost.

Image 2. Otoscope view of acute bacterial OM

If the TM has perforated, there might be sticky discharge in the external canal or you might see a hole in the TM (see image 3).

Image 3. Otoscope view of a child’s perforated TM

It’s not uncommon for it to be impossible to see the TM due to wax in the external ear canal. In that situation you will probably have to make a judgment call, considering other features such as how unwell the patient is and whether there is any other focus for a possible infection. That might well take them out of the range of the Pharmacy First scheme and mean that you need to signpost to the GP.

If there aren’t signs and symptoms of OM then the flowchart advises that you ‘consider alternative diagnoses and proceed appropriately’ – in most cases this will be a viral upper respiratory tract infection (URTI), for which you are probably used to advising on over the counter medication. Note that TMs will often be slightly red in URTI or if a child is crying, and this does not increase the likelihood of OM (especially if it is the same on both sides, as bilateral OM unlikely).

Direct the patient appropriately if you are concerned that something else is going on.

4. If you think the patient has OM, consider if they are at high risk of serious illness

Of those patients with OM, the Pharmacy First flowchart suggests that the sickest cohort are referred for assessment by their GP, or elsewhere depending on local pathways. This would include those who are ‘systemically very unwell’ (not defined, but see point 1 for some ideas about what would constitute this), have signs of a more serious illness, or have a pre-existing co-morbidity that puts them at high risk. As with some of the other Pharmacy First flowcharts, this includes those who are immunosuppressed or who have diseases affecting their cardiac or respiratory symptoms. Think carefully also about those who were born prematurely, particularly if they have ongoing health needs related to their prematurity.

5. Don’t rush to antibiotics if OM suspected

There has been some understandable concern about antimicrobial stewardship with the introduction of Pharmacy First, given the clinical skill and experience required to confidently rule out the need for antibiotics. Be particularly mindful with OM that antibiotics should be reserved for use only where needed.

The Pharmacy First pathway advises antibiotics only for those who have discharge after a suspected or confirmed eardrum perforation, or are aged under two with infection in both ears and severe symptoms for more than three days. This cohort is going to be a small minority of all of those who start at the top of your flowchart; consider auditing your antibiotic use after you’ve been doing Pharmacy First for a month or two, and thinking about whether they are genuinely only being given when absolutely needed.

6. Choose your antibiotics wisely if used

The Pharmacy First flowchart suggests use of amoxicillin, or clarithromycin if there is a penicillin allergy. Remember not to take ‘she’s allergic to penicillin’ at face value – when you enquire more deeply, symptoms attributed to allergy often include things like diarrhoea, vomiting, sore throat, feeling tired or having a temperature, none of which are truly allergic responses.

You might want to check if they have had a penicillin-based antibiotic in the past and if so how they have reacted to it. If they report a rash, swelling or wheezing then this is more likely to have been a genuine penicillin allergic response.

For those who are pregnant and penicillin allergic, erythromycin is advised, though they probably won’t thank you for the resulting vomiting. This is only suggested for those aged 16 or 17, though of course younger teenagers can also get pregnant. The Pharmacy First Patient Group Direction (PGD) is very cautious on this (as is the BNF) – although there is no real reason not to use clarithromycin in pregnancy,⁷ you need to follow the PGD which precludes its use.

7. Always offer safety-netting advice

Whether or not you give antibiotics, don’t forget to safety-net and to document this. Explain to patients that if their symptoms worsen ‘rapidly or significantly’, or don’t improve after 2-3 days of antibiotics, a GP review is advised.

This is the latest in a series of articles on aspects of Pharmacy First from The Pharmacist.  

Dr Toni Hazell is a GP in north London