J Am Board Fam Pract: first published as 10.3122/15572625-12-1-1 on 1 January 1999. Downloaded from ORIGINAL ARTICLES Treatment Patterns for Otitis Externa Michael T. Halpern, MD, PhD, Cynthia S. Palmer, MSc, and Mindel! Seidlin, AID Background: Although otitis extern a is a common and painful infection of the outer ear canal, there is little specific information available regarding current treatment patterns in the United States. We wanted to ex­ amine treatment patterns for otitis externa. Methods: Data were analyzed from the 1993 National Ambulatory Medical Care Survey (NAMCS) and the 1993 National Hospital Ambulatory Medical Care Survey (NHAMCS) for adults and children treated for otitis externa. Data analyses included the reasons for physician visits, concomitant diagnoses, types of physicians seen, sources of payment, medical procedures administered, drugs prescribed, and patient disposition following a physician visit. Results: Study results suggested that treatment patterns differ substantially for adults and children, as well as by physician specialty. Although otitis extern a is frequently painful, few cases are classified as severe, and the data indicated that less than 20 percent of patients have concomitant diagnoses treatable by medication. Nevertheless, 40 percent of patients received both topical and systemic medication, and many of the oral antibiotics prescribed are not active against Staphylococcus aureus or Pseudomonas aerug;nosa, the most common bacterial pathogens in otitis externa. Conclusions: Appropriate treatment of localized otitis externa with topical antibiotics should eliminate the need for systemic medications. Addition of systemic medications can unnecessarily increase treatment costs and the likelihood of side effects, and could reduce the likelihood of patient compliance. 0 Am Board Fam Pract 1999;12:1-7.) Acute otitis externa is a common, painful infection to malignant otitis externa, which can be fataL7 of the outer ear canal. The most common clinical Treatment for otitis externa can include clean­ manifestation of otitis externa is pain, followed by ing the ear as well as topical creams, ointments, or erythema, edema, itching, discharge, and hearing drops containing antiseptics, antibiotics, and loss.I-4 Assessment of severity of otitis externa, steroids.8 There is, however, little specific infor­ http://www.jabfm.org/ rated by physicians on a scale from 0 to 3 based on mation available regarding current treatment pat­ physical findings and symptoms, indicates 44 per­ terns in the United States The types of physicians cent of patients have mild disease, 43 percent have treating otitis externa, procedures performed on moderate disease, and 13 percent have severe dis­ otitis externa patients, and disposition of patients ease. Z Pseudomonas is responsible for approximately subsequent to treatment have not been examined. 60 percent of infections, Staphylococcus for 15 per­ Thus, we undertook this study to evaluate otitis on 25 September 2021 by guest. Protected copyright. cent, fungi for 10 percent, and other organisms for externa treatment patterns using US government the remaining 15 percent of infections.5•6 Compli­ national databases. cations of otitis externa include ear canal stenosis, myringitis and tympanic membrane perforation, Methods regional dissemination of infection (auricular cel­ To evaluate treatment patterns, we analyzed data lulitis, chondritis, and parotitis), and progression on otitis externa from two public databases: the 1993 National Ambulatory Medical Care Survey (NAMCS)9 and the 1993 National Hospital Am­ Submitted, revised, 19 May 1998. bulatory Medical Care Survey (NHAMCS).IO The From MEDTAP International (MTH, CSP), Bethesda, NAMCS and NHAMCS are national probability Md, and Daiichi Pharmaceutical Corporation (MS), Ft. Lee, NJ. Address reprint requests to Michael T. Halpern, 1\lD, sample surveys conducted by the Division of PhD, MEDTAP International, 1701 'Visconsin Ave, Suite Health Care Statistics, National Center for Health 600, Bethesda, MD 20814. This study was funded by Daiichi Pharmaceutical Corpo­ Statistics, Centers for Disease Control and Pre­ ration, Ft. Lee, NJ. vention. These data are weighted to produce na- Treatment for Otitis Extema 1 J Am Board Fam Pract: first published as 10.3122/15572625-12-1-1 on 1 January 1999. Downloaded from tional estimates that describe the utilization of am­ Table l. Demographic Characteristics of Patient Visits. bulatory medical care services in the United States. Percent Data sets from 1993 were the most recent available Visits Patient Age Female for this study. Visit Number (%) Mean Years Patients The NAMCS is a survey of office-based physi­ All 3,314,423 (100) 31.0 52.1 cian practices evaluating patient office visits. Visits Pediatric 1,452,925 (43.8) 9.3 52.2 with federally employed physicians, visits occur­ Adult 1,861,498 (56.2) 48.0 52.0 ring outside an office setting (eg, house calls, nurs­ ing home visits), and visits with anesthesiologists, pathologists, or radiologists were excluded. In sented separately from those for adults (age 18 1993, a total of35,978 patient visits were evalu­ years and older). As no identifying information is ated from 1802 physicians. available in these data sets, longitudinal treatment The NHAMCS evaluates ambulatory care patterns (ie, repeat visits or treatments by the same provided in hospital emergency and outpatient patients or relapse of otitis externa infections) and departments in the United States. For this study, treatment outcomes could not be determined. only information on outpatient department visits was included. Outpatient visit data were collected Results at short-stay and general nonfederal hospitals. In Of the derived 3.3 million outpatient visits associ­ 1993,28,357 patient visits at 228 outpatient de­ ated with otitis externa, 44 percent were pediatric partments were included in the NHAMCS. visits (Table 1). The average ages of patients were The probability sample design of the NAMCS 9 years for children and 48 years for adults. Just and the :NlIfu\1CS allowed the sample data to be more than one half of both adults and children weighted to produce national estimates for the making visits were female. Among adults, most United States. Unweighted data are not used for episodes of otitis externa were treated by family analysis, as unweighted data ignore the dispropor­ practice or general practice physicians (55 per­ tionate sampling used in the NHAMCS. Statistics cent), otolaryngologists or head and neck sur­ from the NAMCS and the NHAMCS were de­ geons (22 percent), and internal medicine physi­ rived by a multistage estimation procedure that cians (12 percent). Pediatric patients received produces essentially unbiased national estimates. most care from pediatricians (57 percent), family The NAMCS and NHAM:CS statistics reflect data practice or general practice physicians (26 per­ http://www.jabfm.org/ concerning only a sample of patient visits, not a cent), internists (7 percent), and otolaryngologists complete count of all the visits that occurred in the or head and neck surgeons (7 percent). The mean United States. Data presented in the NHAMCS duration of physician visits was 12.5 minutes (12.2 and NAMCS include patient demographics (age, minutes for children, 12.7 minutes for adults). sex, race, ethnicity), provider characteristics (spe­ Table 2 displays the reasons for the otitis ex­ cialty, geographic region, metropolitan or non­ terna physician visits as reported by patients. Pa­ metropolitan status), expected source of payment; tients could list up to three reasons per visit. Ear­ on 25 September 2021 by guest. Protected copyright. patient-supplied reason for visit, physician's diag­ ache was cited by a majority of both adult and nosis, patient disposition after the visit, and other child patients. Among adults, ear itch and other medical care resource utilization (tests, procedures, ear symptoms, discharge from the ear, and a or medications) associated with the visit. plugged feeling in the ear were also cited. Approx­ , For this study, we selected all patients with imately 5 percent of adults also visited the physi­ •• medical care visits having the ICD-911 diagnosis cian to obtain a prescription refill or for evaluation code 380.1 (infective otitis externa). Using the of a neck mass (presumably lymphadenopathy). combined data from the NAMCS and NHA!vlCS, Pediatric patients cited discharge from the ear and we found 190 outpatient episodes of otitis extema, a plugged feeling in the ear at a rate similar to that corresponding to a weighted value of approxi­ of adults, but unlike adults, ear itch was cited as a mately 3.3 million outpatient visits. Results de­ reason by less than 1 percent of children. Pediatric scribed here are based on weighted national data. patients described a number of systemic symp­ Information regarding treatment patterns for pe­ toms more frequently than did adults, including diatric patients (age 17 years or younger) are pre- headache, nasal congestion, and cough. Adults 2 JABFP Jan.-Feb.1999 Vol. 12 No.1 J Am Board Fam Pract: first published as 10.3122/15572625-12-1-1 on 1 January 1999. Downloaded from Table 2. Reason for Physician Visit (Percent) for Otitis Table 3. Patient Disposition (Percent) After Physician Extema. Visit for Otitis Extema. Symptom Adult Child Disposition Adult Child Ear symptoms No follow-up 7.1 36.1 Earache 66.8 79.9 Return as needed 33.9 24.7 Discharge from ear 9.1 8.2 Specified appointment 53.7 31.0 Plugged feeling in ear 5.9 5.9 Telephone follow-up 1.9 0.1 Trouble hearing 2.2 3.5 Refer to other physician 3.4 8.1 Ear itch and other symptoms 15.5 0.6 Dizziness 1.5 0.0 Other symptoms otitis externa. The most common procedure for Headache 0.2 4.8 adults was ear irrigation (7 percent), with ear cul­ Nasal congestion 0.7 6.1 ture (6 percent) and audiometry (1 percent) being Chest congestion 1.6 0.0 performed less frequently. Few children experi­ Fever 1.7 1.1 enced ear irrigation (2 percent) or audiometry (<1 Sore throat 3.6 2.3 percent); no ear cultures were reported.