How is otitis externa treated

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Otitis externa — codes and concepts open. Swimmers ear. Eczema or dermatitis, Age site specific, Bacterial infection, Fungal infection, Other inflammatory disorder. External auditory canal, Infections - bacterial and fungal, Aspergillosis, Candidiasis, Pseudomonas, Otomycosis, Otalgia, Otorrhoea, Non-infective otitis externa - atopic dermatitis, seborrhoeic dermatitis, psoriasis, CLE, acne, Irritant contact dermatitis, Allergic contact dermatitis, Secondary bacterial infection.

H60, B References Book: Textbook of Dermatology. Fourth edition. Otitis externa, also called swimmer's ear, is an inflammation, irritation, or infection of the external ear canal. Swimmer's ear is caused by fungi or bacteria. Water that remains trapped in the ear canal when swimming, for example may provide a source for the growth of bacteria and fungi. Many different factors can increase your child's chance of developing swimmer's ear. As the name implies, one of the factors is excessive wetness as with swimming, although it can occur without swimming.

Other possible causes of this infection include the following:. The following are the most common symptoms of swimmer's ear. However, each child may experience symptoms differently. The patient should remain in this position for three to five minutes, after which the canal should not be occluded, but rather left open to dry.

When there is marked canal edema, a wick of compressed cellulose or ribbon gauze may be placed in the canal to facilitate antimicrobial or antibiotic administration.

Wick placement permits antibiotic drops to reach portions of the external auditory canal that are inaccessible because of canal swelling. As the canal responds to treatment and patency returns to the ear canal, the wick often falls out. Pain is a common symptom of acute otitis externa, and can be debilitating. First-line analgesics include nonsteroidal anti-inflammatory drugs and acetaminophen.

When ongoing frequent dosing is required to control pain, medications should be administered on a scheduled rather than as-needed basis. Opioid combination pills may be used when symptom severity warrants.

Benzocaine otic preparations may compromise the effectiveness of otic antibiotic drops by limiting contact between the drop and the ear canal. The lack of published data supporting the effectiveness of topical benzocaine preparations in otitis externa limits the role of such treatments.

Acute otitis externa can be associated with copious material in the ear canal. Consensus guidelines published by the American Academy of Otolaryngology recommend that such material be removed to achieve optimal effectiveness of the topical antibiotics. Guidelines recommend aural toilet by gentle lavage suctioning or dry mopping under otoscopic or microscopic visualization to remove obstructing material and to verify tympanic membrane integrity.

The treatment of chronic otitis externa depends on the underlying causes. Because most cases are caused by allergies or inflammatory dermatologic conditions, treatment includes the removal of offending agents and the use of topical or systemic corticosteroids.

Chronic or intermittent otorrhea over weeks to months, particularly with an open tympanic membrane, suggests the presence of chronic suppurative otitis media. Initial treatment efforts are similar to those for acute otitis media. With control of the symptoms of otitis externa, attention can shift to the management of chronic suppurative otitis media. Most patients will experience considerable improvement in symptoms after one day of treatment.

If there is no improvement within 48 to 72 hours, physicians should reevaluate for treatment adherence, misdiagnosis Table 3 , sensitivity to ear drops, or continued canal patency. The physician should consider culturing material from the canal to identify fungal and antibiotic-resistant pathogens if the patient does not improve after initial treatment efforts or has one or more predisposing risk factors, or if there is suspicion that the infection has extended beyond the external auditory canal.

There is a lack of data regarding optimal length of treatment; as a general rule, antimicrobial otics should be administered for seven to 10 days, although in some cases complete resolution of symptoms may take up to four weeks. Consultation with an otolaryngologist or infectious disease subspecialist may be warranted if malignant otitis externa is suspected; in cases of severe disease, lack of improvement or worsening of symptoms despite treatment, and unsuccessful lavage; or if the primary care physician determines that aural toilet or ear wick insertion is warranted, but is unfamiliar with or concerned about performing the procedure.

Search dates: January 1, , through April 6, Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Reprints are not available from the authors. Br J Gen Pract. An audit of the management of acute otitis externa in an ENT casualty clinic. J Laryngol Otol. The changing face of malignant necrotising external otitis: clinical, radiological, and anatomic correlations.

Lancet Infect Dis. Microbiology of otitis externa in the secondary care in United Kingdom and antimicrobial sensitivity. Auris Nasus Larynx. Microbiology of acute otitis externa. Fungal causes of otitis externa and tympanostomy tube otorrhea. Int J Pediatr Otorhinolaryngol. Otomycosis: a retrospective study. Braz J Otorhinolaryngol. Prospective study of the microbiological flora of hearing aid moulds and the efficacy of current cleaning techniques. What causes acute otitis externa?

Change of external auditory canal pH in acute otitis externa. Ann Otol Rhinol Laryngol. Risk of otitis externa after swimming in recreational fresh water lakes containing Pseudomonas aeruginosa. Treatment patterns for otitis externa. J Am Board Fam Pract. Systematic review of topical antimicrobial therapy for acute otitis externa.

Interventions for acute otitis externa. Cochrane Database Syst Rev. Hajioff D, Mackeith S. Otitis externa. Clin Evid Online. Acute bacterial. Chronic bacterial. Typically fluffy and white to off-white discharge, but may be black, gray, bluish-green or yellow; small black or white conidiophores on white hyphae associated with Aspergillus.

Otorrhea and other debris can occlude the ear canal. Such occlusion makes it difficult to visualize the tympanic membrane and exclude otitis media; it also keeps the canal moist and interferes with topical treatment.

It is imperative that this material be removed. However, inflammation makes the external auditory canal even more vulnerable to trauma than usual, and therefore the use of a cerumen spoon or curette should be avoided.

Cleansing is best done by suctioning under direct visualization, using the open or operating otoscope head and a 5 or 7 Fr Frazier malleable suction tip attached to low suction. Alternatively, a cotton swab with the cotton fluffed out can be used to gently mop out thin secretions from the external auditory canal, again under direct visualization Figure 2.

If the secretions are thick, crusted or adherent, instillation of antibiotic drops or hydrogen peroxide may help to soften them for removal. Unless the tympanic membrane can be fully observed and is found to be intact, flushing of the ear canal should not be attempted. A small perforation is often missed, and a tympanic membrane already weakened by infection can easily be disrupted. Divers, surfers and others who experience forceful compression of the tympanic membrane are particularly susceptible to perforations.

Such damage may necessitate surgery, and a perforated tympanic membrane associated with flushing is a common cause of litigation. If the external auditory canal cannot be easily cleansed because of swelling or pain, discharge and debris should be left in place and the patient should undergo frequent reevaluation until the secretions can be removed or have drained spontaneously.

When the canal is quite swollen, a cotton wick specifically designed for this purpose should be placed to facilitate drainage and permit application of topical medications. A thorough examination of the head and neck should be performed to rule out other diagnoses and to look for possible complications of otitis externa. The examination should include evaluation of the sinuses, nose, mastoids, temporomandibular joints, mouth, pharynx and neck.

In addition, if the tympanic membrane can be visualized and is red, a pneumatoscope or tympanometry should be used to ascertain whether associated otitis media is present. The most common cause of otitis externa is a bacterial infection, although fungal overgrowth is a principal cause in 10 percent of cases. Like all skin, the external auditory canal has a normal bacterial flora and remains free of infection unless its defenses are disrupted. When disruption occurs, a new pathogenic flora develops that is dominated by Pseudomonas aeruginosa and Staphylococcus aureus.

The signs and symptoms of otitis externa with a bacterial etiology tend to be more intense than in other forms of the disease. Otalgia may be severe enough to require systemic analgesics such as codeine and non-steroidal anti-inflammatory drugs NSAIDs. Fever may be present, but if it exceeds Lymphadenopathy just anterior to the tragus is common. Once the external auditory canal has been cleansed as much as possible and a wick inserted if swelling is severe, topical antibacterial therapy should be started.

Because topical agents can be placed in direct contact with the bacteria, simple acidification with 2 percent acetic acid is usually effective, but a wide spectrum of other agents is available Tables 3 and 4. With aluminum acetate Otic Domeboro. With polymyxin B—hydrocortisone Cortisporin.

With hydrocortisone-thonzonium Coly-Mycin S. Ofloxacin 0. Ciprofloxacin 0. Gentamicin sulfate 0. Tobramycin sulfate 0. Based on average wholesale prices in Red book. Montvale, N. Cost to the patient will be higher, depending on prescription filling fee.

Generic product is inexpensive and effective against most infections without causing sensitization. Highly effective without causing local irritation or sensitization; no risk of ototoxicity; twice-daily dosing.

Expensive; increased community exposure of an important class of antibiotics, with potential for causing resistance. The addition of steroids to the ear drops may decrease the inflammation and edema of the canal and resolve symptoms more quickly, but not all studies have shown a benefit. In addition, a topical steroid can be a topical sensitizer. Treatment recommendations vary somewhat, but it is most commonly recommended that drops be given for three days beyond the cessation of symptoms typically five to seven days ; however, in patients with more severe infections, 10 to 14 days of treatment may be required.

There is no need for reevaluation unless the infection is not resolving. A small cotton plug moistened with the drops can be used to help retain the drops in the ear if the patient cannot lie still long enough to allow absorption.

Absorption may also be facilitated by manipulating the tragus to help distribute the drops throughout the external auditory canal. When a wick is required, drops should be applied every three to four hours while the patient is awake. In these cases, the ear canal should be reexamined and cleansed every two to five days until edema of the canal has resolved and the wick is no longer needed.

Oral antibiotics are rarely needed 2 but should be used when otitis externa is persistent, when associated otitis media may be present or when local or systemic spread has occurred.

The latter should be suspected if the patient's temperature is higher than Otitis media should be considered when the patient has had an upper respiratory infection or is younger than two years, an age when otitis externa is uncommon.

Systemic antibiotics also should be considered when the patient has even early signs of necrotizing otitis externa, as described later. Finally, consideration also should be given to starting oral antibiotics early in patients whose immunity may be compromised, such as those with diabetes, those taking systemic corticosteroids or those with an underlying chronic dermatitis. Because ofloxacin otic solution Floxin Otic is the only topical agent to be labeled by the U. Food and Drug Administration FDA for use when the tympanic membrane is perforated, 19 oral antibiotics have traditionally been used in this situation.

However, because the risk of cochlear damage with the use of other topical medications seems quite small, perforation alone is not an indication for oral antibiotics.

When a patient is in a toxic state or the infection is unresponsive to treatment with oral antibiotics, especially in the presence of severe pain and granulation tissue in the ear canal, parenteral antibiotics should be used.

Although topical cultures may be misleading, they are recommended by some authors 6 to help guide treatment in such severe infections. Patients who do not respond rapidly to parenteral therapy should be referred to an otolaryngologist. Whether oral or parenteral, empiric treatment should cover Pseudomonas and Staphylococcus species. This would include agents such as the cephalosporins, penicillinase-resistant penicillins and fluoroquinolones.

Necrotizing or malignant otitis externa is a life-threatening extension of external otitis into the mastoid or temporal bone. Most commonly caused by P. However, all immunocompromised patients, especially those with human immunodeficiency virus HIV infection, are at risk.

Necrotizing otitis externa is difficult to treat, and the mortality rate can be as high as 53 percent. This condition should be suspected when, despite adequate topical treatment, otalgia and headache are disproportionately more severe than the clinical signs or when granulation tissue is apparent at the bony cartilaginous junction. The diagnosis should be confirmed by a computed tomographic CT scan or magnetic resonance imaging MRI.

A combination of technetium scanning to detect osteoblastic activity and gallium 67 imaging to detect granulocytic activity can be used in questionable cases and is recommended by some 4 , 25 as a means of monitoring response to treatment. The erythrocyte sedimentation rate ESR can also be used to monitor therapeutic response. The excellent antipseudomonal activity of the fluoroquinolones has generally made them the treatment of choice for necrotizing otitis externa, although a combination of a beta-lactam antibiotic and aminoglycoside is also effective.

Treatment should also include surgical debridement of any granulation or osteitic bone. Another potential complication of otitis externa is a focal furuncle of the lateral third of the external auditory canal, which can occur as a result of obstructed apopilosebaceous glands.

Localized swelling is usually significant and may include a superficial abscess that can be drained. Treatment consists of local heat and topical and systemic antibiotics to eradicate the most common pathogen, S. Otitis externa may develop into a persistent low-grade infection and inflammation. In these cases, the external auditory canal lacks cerumen and is lined by dry, hypertrophic skin with variable swelling and stenosis.

Mucopurulent otorrhea and excoriated skin may also be present. The causative bacteria vary greatly because many of the patients have already received prolonged topical therapy. At times, only normal flora can be cultured. Treatment consists of the use of acidifying drops combined with steroid drops, but persistent cases require referral to an otolaryngologist for frequent otomicroscopic cleansing and debridement.