eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Otitis Externa: Treatment & Medication

Author: Samuel Lee, MD, Resident Physician, Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Receiving Hospital
Coauthor(s): Adam J Rosh, MD, Assistant Professor, Department of Emergency Medicine, Wayne State University/Detroit Receiving Hospital
Contributor Information and Disclosures

Updated: Aug 4, 2009

Treatment

Emergency Department Care

Care generally involves diagnosing otitis externa, cleaning debris from the canal (if possible), and providing patient education and prescriptions. Use of an ear wick allows for effective delivery of medication into a swollen and narrow auditory canal.

Otitis externa with ear wick in place. Note disc...

Otitis externa with ear wick in place. Note discharge from canal and swelling of canal.

Otitis externa with ear wick in place. Note disc...

Otitis externa with ear wick in place. Note discharge from canal and swelling of canal.


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If the canal is significantly edematous, a foam (Pope) or gauze wick (quarter-inch packing works well) may be inserted to facilitate the delivery of medications. The foam wicks are highly compressed and expand with absorption of liquids. The gauze wick may be wound over the tip of a small metal or wood probe and inserted into the canal. For the first several days, the medication drops are placed on the external end of the wick and carried into the recesses of the ear canal. As the edema decreases, the wick falls out or is removed.

Most physicians prescribe topical antibiotics. Before antibiotic treatment was recommended for otitis externa, astringents and acetic acid solutions (VoSol) were commonly used to treat otitis externa. These solutions can be painful to inflamed ear canals and are not generally used today. An aminoglycoside combined with a second antibiotic and a topical steroid such as neomycin-polymyxin B-hydrocortisone used to be the most commonly prescribed topical antibiotic. However, caution must be used to recognize a hypersensitivity reaction and ototoxicity to the neomycin component.

In the case of a perforated tympanic membrane, it is critical to avoid using the otic solution, which increases the risk of aminoglycoside ototoxicity. In this setting, suspension drops are safer to use.  

A recent literature review concluded that the use of ciprofloxacin 0.3%/dexamethasone 0.1% otic suspension for otitis externa is safe and effective and that dexamethasone improves treatment success.3

Fluoroquinolones are not associated with ototoxicity, and ofloxacin is safe in cases of a perforated tympanic membrane.

Mild fungal infections can usually be treated with an acetic acid solution, whereas more severe cases may require a topical antifungal such as 1% clotrimazole.

Mildly affected, afebrile patients with ear involvement may be closely monitored on an outpatient basis with antibiotics.

Analgesics, antipruritics, and antihistamines may be indicated.

Clinical guidelines are available from the American Academy of Otolaryngology - Head and Neck Surgery Foundation.4

Consultations

In general, consulting an otorhinolaryngologist (ENT) for simple otitis externa is not necessary. However, consultation is appropriate if the patient has a suppurative complication, a perforated tympanic membrane, or if malignant otitis externa is suspected.

Medication

The agents used include analgesics for pain relief and acidifying solution to treat the infection. Otic antibiotic and steroid combinations have shown to be highly successful in treatment. Oral antibiotics in combination with otic antibiotic solutions have not shown to improve treatment success rates.5

Analgesics

Otitis externa can be quite painful and patients frequently request analgesics. Inexpensive, simple nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids are appropriate. In some cases, systemic analgesics are helpful before ear cleaning or wick placement.


Acetaminophen and codeine (Tylenol-3)

Indicated for treatment of mild to moderate pain.

Adult

1-2 tab PO q4-6h; not to exceed 4 g/d acetaminophen

Pediatric

0.5-1 mg/kg/dose PO q4-6h based on codeine; 10-15 mg/kg/dose PO based on acetaminophen; not to exceed 2.6 g/d acetaminophen

Toxicity increases with CNS depressants or tricyclic antidepressants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients dependent on opiates because substitution may cause acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Acidifying agents

Inflammation and accumulated debris allow the growth of Pseudomonas species. This growth is counteracted by the use of mild acidifying medications, such as acetic acid solutions (eg, VoSol).


Acetic acid solution (VoSol)

Inexpensive agent; works well in treating superficial bacterial infections of otitis externa.

Adult

1-2 gtt q4-6h in canal or on ear wick

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

For external use only; systemic acidosis may result from absorption

Otic antibiotics

These agents are commonly prescribed for treating otitis externa and are associated with cure rates between 87% and 97%.3


Ciprofloxacin-dexamethasone otic (Ciprodex otic suspension)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but not anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth. Dexamethasone decreases external auditory canal swelling and relieves pain symptoms.

Adult

4 gtt q12h into affected ear

Pediatric

3 gtt q12h into affected ear

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Superinfections (usually fungal) may occur with prolonged or repeated antibiotic use


Neomycin, polymyxin B, and hydrocortisone (Cortisporin Otic)

Antibacterial and anti-inflammatory solution for otic use. Treats superficial bacterial infections of external auditory canal.

Adult

4-5 gtt q6h into affected ear

Pediatric

4 gtt q6h into affected ear

Documented hypersensitivity; viral infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Extended use can lead to resistant infections and skin thinning or atrophy; caution in patients with perforated TMs because of possible ototoxicity; as many as one third may develop allergic hypersensitivity to neomycin component, with redness and inflammation mimicking persistent infection; a few patients have more severe local reaction


Ofloxacin (Floxin Otic)

Pyridine carboxylic acid derivative with broad-spectrum bactericidal effect.

Adult

5-10 gtt q12h into affected ear

Pediatric

5 gtt q12h into affected ear

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Superinfections (usually fungal) may occur with prolonged or repeated antibiotic use


Ciprofloxacin (Ciloxan, Cipro HC Otic)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but not anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Adult

3-5 gtt q12h into affected ear

Pediatric

3 gtt q12h into affected ear

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Superinfections (usually fungal) may occur with prolonged or repeated antibiotic use

More on Otitis Externa

Overview: Otitis Externa
Differential Diagnoses & Workup: Otitis Externa
Treatment & Medication: Otitis Externa
Follow-up: Otitis Externa
Multimedia: Otitis Externa
References

References

  1. Roland PS, Stroman DW. Microbiology of acute otitis externa. Laryngoscope. Jul 2002;112(7 Pt 1):1166-77. [Medline].

  2. Osguthorpe JD, Nielsen DR. Otitis externa: Review and clinical update. Am Fam Physician. Nov 1 2006;74(9):1510-6. [Medline].

  3. Wall GM, Stroman DW, Roland PS, Dohar J. Ciprofloxacin 0.3%/dexamethasone 0.1% sterile otic suspension for the topical treatment of ear infections: a review of the literature. Pediatr Infect Dis J. Feb 2009;28(2):141-4. [Medline].

  4. [Guideline] Rosenfeld RM, Brown L, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. Apr 2006;134(4 Suppl):S4-23. [Medline][Full Text].

  5. Roland PS, Belcher BP, Bettis R, Makabale RL, Conroy PJ, Wall GM, et al. A single topical agent is clinically equivalent to the combination of topical and oral antibiotic treatment for otitis externa. Am J Otolaryngol. Jul-Aug 2008;29(4):255-61. [Medline].

  6. Beers SL, Abramo TJ. Otitis externa review. Pediatr Emerg Care. Apr 2004;20(4):250-6. [Medline].

  7. Block SL. Otitis externa: providing relief while avoiding complications. J Fam Pract. Aug 2005;54(8):669-76. [Medline].

  8. Kim D, Bhimani M. Ramsay Hunt syndrome presenting as simple otitis externa. CJEM. May 2008;10(3):247-50. [Medline].

  9. Niparko JK. Hearing loss and associated problems. In: Principles of Ambulatory Medicine. 4th ed. Lippincott Williams & Wilkins; 1995:1408-9.

  10. Rahman A, Rizwan S, Waycaster C, Wall GM. Pooled analysis of two clinical trials comparing the clinical outcomes of topical ciprofloxacin/dexamethasone otic suspension and polymyxin B/neomycin/hydrocortisone otic suspension for the treatment of acute otitis externa in adults and children. Clin Ther. Sep 2007;29(9):1950-6. [Medline].

  11. Rosenfeld RM, Singer M, Wasserman JM, Stinnett SS. Systematic review of topical antimicrobial therapy for acute otitis externa. Otolaryngol Head Neck Surg. Apr 2006;134(4 Suppl):S24-48. [Medline].

Further Reading

Keywords

otitis externa, swimmer's ear, ear ache, ear infection, otitis externa treatment, otitis externa symptoms, external ear canal infection, external otitis, malignant external otitis, eczematous otitis externa, malignant otitis externa

Contributor Information and Disclosures

Author

Samuel Lee, MD, Resident Physician, Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Receiving Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

Adam J Rosh, MD, Assistant Professor, Department of Emergency Medicine, Wayne State University/Detroit Receiving Hospital
Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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