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Otitis Externa: Treatment & Medication
Updated: Nov 30, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
The primary treatment of otitis externa involves the management of pain, removal of debris from the external auditory canal, use of topical medications to control edema and infection, and avoidance of the contributing factors.
- Gently cleanse debris from the external auditory canal with irrigation or by using a soft plastic curette or cotton swab under direct visualization. Cleansing the canal improves the effectiveness of the topical medication.
- Topical aural medications typically include a mild acid (to alter the pH and to inhibit the growth of microorganisms), a corticosteroid (to decrease inflammation), an antibacterial agent, and/or an antifungal agent. Rosenfeld et al conducted a systematic review of treatment for otitis externa and demonstrated little overall difference in the topical agents that are used to treat otitis externa11 ; however, the authors found that use of a topical steroid alone increased cure rates by 20% compared with a steroid/antibiotic combination.
- Mild infections: Mild otitis externa usually responds to the use of an acidifying agent and a corticosteroid. As an alternative, a 2:1 ratio mixture of 70% isopropyl alcohol and acetic acid may be used.
- Moderate infections: Consider the addition of antibacterial and antifungal agents to the acidifying agent and corticosteroid.
- Oral antibiotics are generally reserved for use in patients with fevers, immunosuppression, diabetes, adenopathy, or in those individuals with extension of the infection outside of the ear canal.
- In some cases, a gauze wick (1/4 inch in length) can be inserted into the canal, and the ototopic medication(s) can be applied directly to the wick (2-4 times daily depending upon the frequency of dosing for the medication). If a wick is used, it should be removed 24-72 hours after insertion.
- In the setting of a patient with a tympanostomy tube or known perforation, a non-ototoxic topical preparation should be prescribed (eg, fluoroquinolone, with or without a steroid).
- In the setting of chronic, noninfectious, therapy-resistant external otitis, a prospective study by Caffier et al demonstrated that the daily use of 0.1% tacrolimus cream (via a wick that was changed every second to third day) resulted in high rates of resolution (46% through a 1-2 y follow-up) after 9-12 days of therapy.12 The study also demonstrated longer periods of symptom-free intervals for those who experienced a recurrence.
Consultations
Consult an otorhinolaryngologist for patients whose cases are refractory to treatment regimens, for those with necrotizing otitis externa, and for those who develop any complications (see Complications).
Activity
Individuals who are involved in aquatic activities should keep the ear dry during the course of treatment for otitis externa. This may be accomplished by avoiding aquatic activities all together, but more often, it is achieved by limiting water activities to those that do not expose the ear to the water (eg, kicking while using a foam floatation board to keep the head above water). Typically, a swimming athlete with otitis externa spends the first 2-3 days out of the water, and then he or she may return to the water activity but should continue to keep the head above the water until the symptoms resolve.
Medication
Most cases of otitis externa can be treated with over-the-counter analgesia and antibiotic eardrops. In severe cases, oral or intravenous (IV) antibiotic therapy and narcotic analgesics may be required. In the case of necrotizing otitis externa, the patient must be admitted to a hospital for IV antibiotics at the discretion of the consulting otorhinolaryngologist. The treatment that is rendered is dependent on the likely organism, which is best evaluated with a Gram stain of the affected area.
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort and may have sedating properties.
Acetaminophen (Tylenol, Feverall, Aspirin-Free Anacin)
Over-the-counter acetaminophen is appropriate for most patients. DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult
650-1000 mg PO q6h prn
Pediatric
10-15 mg/kg PO q4h prn
Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
Documented hypersensitivity; known G6PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity is possible following various dose levels in those with chronic alcoholism; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses that exceed the recommended maximum dose.
Acetaminophen and codeine (Tylenol #3)
Indicated for the treatment of mild to moderate pain
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab PO q4h; not to exceed 4 g/d of acetaminophen
Pediatric
0.5 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of 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 who are dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction
Antibiotic/corticosteroid, Otic
Most cases of otitis externa are caused by superficial bacterial infections. The small amount of steroid that is present in the solution can help to ease the pain and edema associated with this condition.
Gentamicin (Garamycin, Gentacidin)/betamethasone (Celestone phosphate) otic drop
Compounded medication. Each mL contains 3 mg of gentamicin sulfate and 1 mg of betamethasone sodium phosphate
Adult
2-3 gtt on affected side qid
Pediatric
Administer as in adults
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance the effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase the ototoxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly).
Documented hypersensitivity; patients with non–dialysis-dependent renal insufficiency
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
Some literature suggests that ototoxicity (hearing loss) is caused by the topical otic gentamicin, but the relationship is not clear at this time; narrow therapeutic index (not intended for long-term therapy); caution in patients with renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in patients with renal impairment
Ciprofloxacin 0.3% /Dexamethasone 0.1% (Ciprodex)
This otic suspension is indicated for use in otitis externa, as well as otitis media in individuals with tympanostomy tubes.
Adult
4 gtt in affected external auditory canal bid × 7 d
Pediatric
< 6 months: Not indicated
>6 months: 4 gtt in affected external auditory canal bid × 7days.
None reported
Documented hypersensitivity; viral infections affecting external ear canal (eg, herpes simplex)
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 otic use only; warm bottle in hand and shake well before administration; avoid contaminating applicator tip; prolonged use may cause bacterial or fungal overgrowth (discontinue if superinfection or hypersensitivity occurs); rare adverse effects include ear discomfort, ear pain, ear residue, and ear pruritus; re-evaluate if no improvement after 7 d.
Antifungal Agent, Topical
A small but significant percentage of otitis externa cases are due to the Aspergillus species. The mechanism of action usually involves inhibiting the pathways (eg, enzymes, substrates, transport) that are necessary for sterol/cell membrane synthesis or for altering the permeability of the fungal cell membrane (eg, polyenes).
Clotrimazole 1% otic solution (Lotrimin AF)
Compounded medication. Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells.
Adult
4 gtt qid into affected side
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Not for treatment of systemic fungal infections; avoid contact with the eyes; if irritation or sensitivity develops, discontinue use and institute appropriate therapy
More on Otitis Externa |
| Overview: Otitis Externa |
| Differential Diagnoses & Workup: Otitis Externa |
 Treatment & Medication: Otitis Externa |
| Follow-up: Otitis Externa |
| References |
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References
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Cantor RM. Otitis externa and otitis media. A new look at old problems. Emerg Med Clin North Am. May 1995;13(2):445-55. [Medline].
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].
Osguthorpe JD, Nielsen DR. Otitis externa: review and clinical update. Am Fam Physician. Nov 1 2006;74(9):1510-6. [Medline]. [Full Text].
Russell JD, Donnelly M, McShane DP, Alun-Jones T, Walsh M. What causes acute otitis externa?. J Laryngol Otol. Oct 1993;107(10):898-901. [Medline].
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Rowlands S, Devalia H, Smith C, Hubbard R, Dean A. Otitis externa in UK general practice: a survey using the UK General Practice Research Database. Br J Gen Pract. Jul 2001;51(468):533-8. [Medline]. [Full Text].
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Clark WB, Brook I, Bianki D, Thompson DH. Microbiology of otitis externa. Otolaryngol Head Neck Surg. Jan 1997;116(1):23-5. [Medline].
Grandis JR, Curtin HD, Yu VL. Necrotizing (malignant) external otitis: prospective comparison of CT and MR imaging in diagnosis and follow-up. Radiology. Aug 1995;196(2):499-504. [Medline]. [Full Text].
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].
Caffier PP, Harth W, Mayelzadeh B, Haupt H, Sedlmaier B. Tacrolimus: a new option in therapy-resistant chronic external otitis. Laryngoscope. Jun 2007;117(6):1046-52. [Medline].
Bath AP, Walsh RM, Bance ML, Rutka JA. Ototoxicity of topical gentamicin preparations. Laryngoscope. Jul 1999;109(7 pt 1):1088-93. [Medline].
Beers SL, Abramo TJ. Otitis externa review. Pediatr Emerg Care. Apr 2004;20(4):250-6. [Medline].
Rosen P, Barkin RM, Hayden SR, Schaider JJ, Wolfe R. Otitis externa. The 5 Minute Emergency Medicine Consult. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:796-7.
Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 5th ed. New York, NY: McGraw-Hill Professional Publishing; 2000:1521-3.
Further Reading
Keywords
swimmer's ear, acute diffuse otitis externa, acute localized otitis externa, necrotizing otitis externa, eczematous otitis externa, infection of the external auditory canal
