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Otitis Externa: Treatment & Medication
Updated: Aug 4, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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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 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
Documented hypersensitivity
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
None reported
Documented hypersensitivity
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
None reported
Documented hypersensitivity
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
None reported
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
None reported
Documented hypersensitivity
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
None reported
Documented hypersensitivity
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 |
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References
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, 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].
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].
Kim D, Bhimani M. Ramsay Hunt syndrome presenting as simple otitis externa. CJEM. May 2008;10(3):247-50. [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].
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
