From the Guidelines
Otitis externa that does not respond to standard otic treatments may require more aggressive management and vigilance for complications, particularly in diabetic or immunocompromised patients, who are at higher risk of developing necrotizing otitis externa, a serious condition that requires immediate hospitalization for IV antipseudomonal antibiotics. When initial treatments like antibiotic ear drops (such as ciprofloxacin/dexamethasone or neomycin/polymyxin B/hydrocortisone) fail after 7-10 days, consider alternative diagnoses or complications, as suggested by 1. Complications of persistent otitis externa include:
- Malignant (necrotizing) otitis externa, which presents with severe ear pain, purulent discharge, granulation tissue in the ear canal, and potentially cranial nerve involvement (particularly facial nerve palsy) 1
- Otomycosis, or fungal infection of the external ear canal, which is common in tropical countries, humid locations, after long-term topical antibiotic therapy, and in those with diabetes, HIV infection, or an immunocompromised state, and may present with pruritus and thickened otorrhea 1
- Cellulitis of surrounding tissues, hearing loss, and stenosis of the ear canal Warning signs requiring urgent evaluation include:
- Fever
- Severe pain disproportionate to exam findings
- Cranial nerve deficits
- Extension of inflammation beyond the ear canal Management of refractory cases may require:
- Culture-directed therapy
- Oral antibiotics (like ciprofloxacin 500mg twice daily for 7-10 days)
- Careful debridement of the ear canal by an otolaryngologist
- Addressing underlying conditions such as diabetes or immunosuppression that may impair healing, as recommended by 1 and 1.
From the Research
Possible Complications of Otitis Externa
- Malignant otitis externa: a severe infection that can spread to the skull and brain, especially in people with weakened immune systems 2, 3
- Temporal bone osteomyelitis: an infection of the bone in the skull that can cause severe pain and hearing loss 2
- Facial nerve paralysis: a condition that can cause weakness or paralysis of the facial muscles 3
- Sigmoid sinus thrombosis: a blood clot in the sinus that can cause severe headaches and fever 4
- Brain abscess: a rare but potentially life-threatening complication of otitis externa 5, 6
Presenting Symptoms of Complications
- Severe pain or tenderness in the ear or surrounding area
- Fever or chills
- Hearing loss or ringing in the ears
- Weakness or paralysis of the facial muscles
- Severe headaches or confusion
- Redness or swelling of the ear or surrounding area
- Discharge or pus from the ear
- Difficulty speaking or swallowing
Treatment of Complications
- Antibiotics: to treat bacterial infections and prevent further complications 2, 3, 4, 5, 6
- Pain management: to relieve severe pain and discomfort 2, 3, 4
- Surgical intervention: to drain abscesses or repair damaged tissue 5, 6
- Hospitalization: to monitor and treat severe complications, such as malignant otitis externa or brain abscess 2, 3, 4, 5, 6