Otitis Externa Treatment & Management

  • Author: Joseph P Garry, MD, FACSM, FAAFP; Chief Editor: Craig C Young, MD   more...
 
Updated: Feb 28, 2010
 

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 externa[11] ; 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.
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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).

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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.

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Contributor Information and Disclosures
Author

Joseph P Garry, MD, FACSM, FAAFP  Associate Professor, Sports Medicine Faculty, Department of Family and Community Medicine, University of Minnesota Medical School

Joseph P Garry, MD, FACSM, FAAFP is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Heart Association, American Medical Society for Sports Medicine, and North American Primary Care Research Group

Disclosure: Nothing to disclose.

Coauthor(s)

Sanjiv K Bhalla, MD  Consulting Staff, Department of Emergency Medicine, St Paul's Hospital of Vancouver, St Joseph's Hospital of Hamilton

Sanjiv K Bhalla, MD is a member of the following medical societies: American College of Emergency Physicians, British Columbia Medical Association, Canadian Association of Emergency Physicians, Canadian Medical Association, Canadian Medical Protective Association, and Ontario Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Andrew L Sherman, MD, MS  Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman, Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency Programs, Department of Rehabilitation Medicine, University of Miami, Leonard A Miller School of Medicine

Andrew L Sherman, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Pfizer Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Russell D White, MD  Professor of Medicine, Professor of Orthopedic Surgery, Director of Sports Medicine Fellowship Program, Medical Director, Sports Medicine Center, Head Team Physician, University of Missouri-Kansas City Intercollegiate Athletic Program, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD  Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Director of Primary Care Sports Medicine Fellowship, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

References

  1. Bojrab DI, Bruderly T, Abdulrazzak Y. Otitis externa. Otolaryngol Clin North Am. Oct 1996;29(5):761-82. [Medline].

  2. 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].

  3. 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].

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

  5. 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].

  6. Holten KB, Gick J. Management of the patient with otitis externa. J Fam Pract. Apr 2001;50(4):353-60. [Medline]. [Full Text].

  7. 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].

  8. Hughes E, Lee JH. Otitis externa. Pediatr Rev. Jun 2001;22(6):191-7. [Medline].

  9. Clark WB, Brook I, Bianki D, Thompson DH. Microbiology of otitis externa. Otolaryngol Head Neck Surg. Jan 1997;116(1):23-5. [Medline].

  10. 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].

  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].

  12. 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].

  13. Bath AP, Walsh RM, Bance ML, Rutka JA. Ototoxicity of topical gentamicin preparations. Laryngoscope. Jul 1999;109(7 pt 1):1088-93. [Medline].

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

  15. 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.

  16. 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.

 
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