eMedicine Specialties > Pediatrics: Surgery > Otolaryngology

Otitis Externa: Treatment & Medication

Author: Ariel A Waitzman, MD, FRCS(C), Assistant Professor of Otolaryngology, Wayne State University
Contributor Information and Disclosures

Updated: Nov 24, 2009

Treatment

Medical Care

  • Topical treatment
    • Most cases of acute otitis externa (OE) respond well to topical treatment.
    • Antibiotic eardrops, with or without a steroid, are the mainstay of treatment.
    • Topical acidifying and drying agents may be used in mild or resolving cases and are useful in fungal infections.
    • Some patients require strong analgesics for the first few days of treatment.
  • Oral antibiotics
    • Most persons with OE do not require oral medications.
    • Administer oral antibiotics in individuals with cellulitis of the face or neck skin or in persons in whom severe edema of the ear canal limits penetration of topical agents.
    • Consider oral antibiotics in patients who are immunocompromised.
  • Intravenous antibiotics
    • Intravenous (IV) antibiotics are used in individuals with necrotizing OE.
    • They may also be appropriate in patients with severe cellulitis or in persons whose symptoms do not respond to topical and oral antibiotics.
    • A prolonged course of IV antibiotics lasting as many as 6 weeks may be needed for individuals with necrotizing OE.
    • If the patient is stable, IV antibiotics may be administered at home.
    • Begin treatment with antibiotics to cover pseudomonads and alter medication depending on culture results.

Surgical Care

  • Debridement
    • Surgical debridement is occasionally required in individuals with necrotizing (ie, malignant) OE.
    • Debridement of the ear canal is often necessary in more severe cases of OE or when a significant amount of discharge is present in the ear.
    • An otolaryngologist usually performs debridement using magnification and suction equipment.
    • Debridement is the mainstay of treatment for fungal infections.
  • Incision and drainage
    • Occasionally, an abscess forms in the ear canal. This usually occurs in OE caused by S aureus.
    • The abscess often requires a simple incision and drainage procedure that is usually performed by an otolaryngologist using a needle or small blade.

Consultations

  • Consider consultation with an otolaryngologist for persons with severe OE or when the patient does not respond to treatment as expected. Debridement of the ear canal is often necessary for resolution of the infection (see Surgical Care).
  • Necrotizing OE necessitates consultation with otolaryngology, infectious disease, and, in some instances, neurosurgery.

Activity

  • During treatment of OE and for 1-2 weeks following its resolution, advise the patient to keep the ear canal dry.
  • During bathing or showering, advise the patient to place an earplug or cotton ball lightly coated with petroleum jelly in the ear canal to prevent water penetration.

Medication

Otic antibiotic agents

Most individuals with otitis externa (OE) may be treated with topical antibiotic preparations. Some preparations also contain a corticosteroid ingredient to decrease inflammation.


Neomycin, polymyxin B, hydrocortisone (Cortisporin Otic)

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

Adult

4-5 gtt instilled to affected ear qid

Pediatric

4 gtt instilled to affected ear qid

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 thinning or atrophy of skin; use with caution in patients with perforated TMs because of possible ototoxicity; as many as one third of patients may develop allergic hypersensitivity to neomycin component with redness and inflammation that may mimic persisting 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 instilled to affected ear bid

Pediatric

5 gtt instilled to affected ear bid

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 with no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Adult

3-5 gtt instilled to affected ear bid

Pediatric

3 gtt instilled to affected ear bid

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


Tobramycin and dexamethasone (TobraDex)

Tobramycin interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in defective bacterial cell membrane. Dexamethasone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Adult

5 gtt instilled to affected ear bid

Pediatric

Administer as in adults

Effects decreased when used concurrently with gentamicin

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Probably should not use when eardrum perforation or ventilation tube is present because of possible ototoxicity


Gentamicin (Garamycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage.

Adult

5 gtt instilled to affected ear tid/qid

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

Probably should not use when eardrum perforation or ventilation tube is present because of possible ototoxicity; do not use to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to secondary infections


Ciprofloxacin and dexamethasone otic (Ciprodex)

Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Has no activity against anaerobes.
Dexamethasone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Adult

4 gtt bid instilled in affected ear or ears for 7 d

Pediatric

<6 months: Not established
>6 months: Administer as in adults

Documented hypersensitivity; viral infections that affect external ear canal

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; rare adverse effects include ear discomfort, ear pain, ear residue, and ear pruritus

Otic acidifying agents

These agents are useful in fungal OE or in mild infections believed to be bacterial. They can also be useful for prevention.


Acetic acid in aluminium acetate (Domeboro)

Aluminium acetate has drying effect. Acetic acid works well in superficial bacterial infections of OE.

Adult

5 gtt instilled to affected ear bid/qid

Pediatric

Administer as in adults

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Avoid use when eardrum perforation or ventilation tube is present; for external use only


Hydrocortisone and acetic acid otic solution (VoSoL, VoSoL HC)

Acetic acid is antibacterial and antifungal; hydrocortisone is anti-inflammatory, antiallergic, and antipruritic. Works well in superficial bacterial infections of OE.

Adult

5 gtt bid/qid 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

Avoid use when eardrum perforation or ventilation tube is present; for external use only; systemic acidosis may result from absorption


Alcohol vinegar otic mix

Homemade mix of 50% rubbing alcohol, 25% white vinegar, and 25% distilled water is as effective as pharmaceutical acidifying agents and less expensive. Very useful for prevention and can be used as flushing solution for fungal infections.

Adult

4-6 gtt instilled in affected ear bid/qid

Pediatric

Administer as in adults

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Avoid use when eardrum perforation or ventilation tube is present

Oral antibiotics

These agents are used to treat severe infection or cellulitis. Fluoroquinolones are drugs of choice because of Pseudomonas species coverage.


Ciprofloxacin (Cipro)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms but with no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Adult

250-500 mg PO bid

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

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

In prolonged therapy, periodically evaluate organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

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

  1. Rowlands S, Devalia H, Smith C, et al. 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].

  2. Roland PS. Chronic external otitis. Ear Nose Throat J. Jun 2001;80(6 Suppl):12-6. [Medline].

  3. Benjamin B, Bingham B, Hawke M. A Colour Atlas of Otorhinolaryngology. London, UK: Martin Dunitz Ltd; 1995.

  4. Bluestone CD, Klein JO. Otitis Media in Infants and Children. Philadelphia, PA: WB Saunders; 1988.

  5. Hawke M, Jahn AF. Diseases of the Ear: Clinical and Pathologic Aspects. Philadelphia, PA: JB Lippincott Co; 1988.

  6. Hawke M, Keene M, Alberti PW. Clinical Otoscopy: An Introduction to Ear Diseases. Edinburgh, UK: Churchill Livingstone; 1990.

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

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

  9. Tierney PA, Price T, Gillet D. Improving standards in the treatment of acute otitis externa by the use of a treatment protocol and open access to aural toilet. J Laryngol Otol. Feb 2001;115(2):87-90. [Medline].

  10. Waitzman AA, Hawke, M. Otoscopic examination: what to look for in the external ear. Consultant. 1996;36(5).

  11. Walshe P, Rowley H, Timon C. A worrying development in the microbiology of otitis externa. Clin Otolaryngol. Jun 2001;26(3):218-20. [Medline].

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Further Reading

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Keywords

otitis externa, OE, necrotizing otitis externa, NOE, malignant otitis externa, swimmer's ear, cellulitis, Pseudomonas aeruginosa, Staphylococcus aureus, Candida, Aspergillus, otalgia, lymphadenitis, hearing loss, tinnitus

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Contributor Information and Disclosures

Author

Ariel A Waitzman, MD, FRCS(C), Assistant Professor of Otolaryngology, Wayne State University
Ariel A Waitzman, MD, FRCS(C) is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, Michigan State Medical Society, and Ontario Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Orval Brown, MD, Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
Orval Brown, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

John E McClay, MD, Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical School
John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Glenn C Isaacson, MD, FACS, FAAP, Professor of Otolaryngology-Head and Neck Surgery and Pediatrics, Temple University School of Medicine
Glenn C Isaacson, MD, FACS, FAAP is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Society of Pediatric Otolaryngology, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Covidien Honoraria Consulting

 
 
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