Otitis Externa in Emergency Medicine Treatment & Management
- Author: Samuel Lee, MD, MS; Chief Editor: Pamela L Dyne, MD more...
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 (shown in the image below) allows for effective delivery of medication into a swollen and narrow auditory canal.
Otitis externa with ear wick in place. Note discharge from canal and swelling of canal. 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.
One 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.
Roland PS, Stroman DW. Microbiology of acute otitis externa. Laryngoscope. Jul 2002;112(7 Pt 1):1166-77. [Medline].
Osguthorpe JD, Nielsen DR. Otitis externa: Review and clinical update. Am Fam Physician. Nov 1 2006;74(9):1510-6. [Medline].
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].
[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].
Roland PS, Belcher BP, Bettis R, 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].
Kim D, Bhimani M. Ramsay Hunt syndrome presenting as simple otitis externa. CJEM. May 2008;10(3):247-50. [Medline].
Beers SL, Abramo TJ. Otitis externa review. Pediatr Emerg Care. Apr 2004;20(4):250-6. [Medline].
Block SL. Otitis externa: providing relief while avoiding complications. J Fam Pract. Aug 2005;54(8):669-76. [Medline].
Niparko JK. Hearing loss and associated problems. In: Principles of Ambulatory Medicine. 4th ed. Lippincott Williams & Wilkins; 1995:1408-9.
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].
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].
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