What is the diagnosis and treatment for Otitis Externa (inflammation of the outer ear)?

From the Guidelines

Otitis externa can be effectively treated with topical antibiotic ear drops, and I recommend using ciprofloxacin/dexamethasone (Ciprodex) or ofloxacin (Floxin) 3-4 drops in the affected ear twice daily for 7-10 days, as supported by the clinical practice guideline 1. For mild to moderate cases, this treatment approach is sufficient, and there is no consistent advantage shown for any one specific drug over another 1. Before applying drops, gently cleaning the ear canal with a bulb syringe using a solution of equal parts white vinegar and rubbing alcohol can help remove debris and restore the ear's natural acidic environment. Pain management is also crucial, and taking acetaminophen (Tylenol) 650mg every 6 hours or ibuprofen (Advil) 400mg every 6 hours as needed can help alleviate symptoms, as emphasized in the guideline on pain management in acute otitis externa 1. During treatment, it is essential to keep the ear dry by avoiding swimming and using earplugs or cotton balls coated with petroleum jelly when showering. The infection occurs when the protective layer of the ear canal is compromised, allowing bacteria (commonly Pseudomonas aeruginosa or Staphylococcus aureus) or fungi to proliferate. If symptoms worsen, include fever, or if there's significant swelling that prevents medication from entering the ear canal, seeking medical attention immediately is necessary, as oral antibiotics or specialized cleaning by a healthcare provider may be required, as noted in the clinical practice guideline 1. Some key considerations for managing otitis externa include:

• Avoiding scratching or touching the ear and not inserting anything into the ear canal, including cotton-tipped swabs 1
• Covering the opening of the ear canal with an earplug or cotton (with petroleum jelly) prior to showering or hair washing to minimize water entry 1
• Notifying the doctor if pain or other symptoms fail to respond within 48 to 72 hours, as this may indicate a need for alternative treatment or further evaluation 1.

From the FDA Drug Label

Ciprofloxacin and dexamethasone otic suspension is indicated for the treatment of infections caused by susceptible isolates of the designated microorganisms in the specific condition listed below: Acute Otitis Externa (AOE) in pediatric (age 6 months and older), adult and elderly patients due to Staphylococcus aureus and Pseudomonas aeruginosa. The recommended dosage regimen for the treatment of Acute Otitis Externa is: Four drops instilled into the affected ear twice daily for seven days. Key points:

• The drug is used to treat Acute Otitis Externa caused by Staphylococcus aureus and Pseudomonas aeruginosa.
• The recommended dosage is four drops twice daily for seven days.
• The drug is for otic use only and should not be used in the eye. 2

From the Research

Causes and Symptoms of Otitis Externa

• Otitis externa is most commonly caused by infection (usually bacterial, although occasionally fungal), but it may also be associated with a variety of noninfectious systemic or local dermatologic processes 3.
• The most characteristic symptom is discomfort that is limited to the external auditory canal, while the most characteristic signs are erythema and swelling of the canal with variable discharge 3.
• Excessive moisture and trauma, both of which impair the canal's natural defenses, are the two most common precipitants of otitis externa 3.

Treatment and Prevention of Otitis Externa

• Thorough cleansing of the canal is essential for diagnosis and treatment, but flushing should be avoided 3.
• Acidification with a topical solution of 2 percent acetic acid combined with hydrocortisone for inflammation is effective treatment in most cases and, when used after exposure to moisture, is an excellent prophylactic 3.
• Topical antimicrobial treatments lead to a higher cure rate than placebo, and corticosteroid preparations lessen swelling, erythema, and secretions 4.
• Antiseptic, steroid and antibiotic monotherapies are all effective for the management of acute otitis externa, with no significant differences in cure rates 5.
• Topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa, with the choice of topical intervention not appearing to influence the therapeutic outcome significantly 6.

Comparison of Treatments for Otitis Externa

• Ciprofloxacin 0.3%/dexamethasone 0.1% (CIP/DEX) was compared with neomycin 0.35%(polymyxin B 10,000 IU/mL/hydrocortisone 1.0% (NPH) for relief of pain in patients with acute otitis externa, with CIP/DEX-treated patients having higher percentages of relief of severe pain over time 7.
• A systematic review and meta-analysis found that non-antibiotic therapeutics, including antiseptics and steroids, were effective for the treatment of acute otitis externa, with no significant differences in cure rates compared to topical antibiotic agents 5.
• A Cochrane review found that topical antimicrobials containing steroids were significantly more effective than placebo drops, but there were no clinically meaningful differences in clinical cure rates between the various topical interventions reviewed 6.