What is the next step in treating a child with persistent severe swelling of the external auditory canal due to otitis externa after 2 days of ototopical (ear drop) antibiotic/corticosteroid therapy?

From the Guidelines

For a child with persistent severe swelling of the external auditory canal due to otitis externa after 2 days of ototopical antibiotic/corticosteroid therapy, the next step should be insertion of an ear wick to facilitate medication delivery. This approach is necessary because severe edema often prevents topical medications from reaching the infected areas, rendering initial treatment ineffective 1. An ear wick (typically made of compressed cotton or cellulose) should be gently placed into the ear canal to allow the antibiotic drops to penetrate past the swelling. Continue the same ototopical medication, but now apply it to the wick, which will expand and deliver the medication deeper into the canal. The wick should remain in place for 48-72 hours while continuing drops 3-4 times daily. After this period, reassess the ear; the wick can be removed once swelling has decreased sufficiently to allow direct application of drops.

Key considerations in managing otitis externa include:

• Ensuring the ear canal is clear of debris and cerumen to facilitate medication delivery 1
• Avoiding aural lavage in patients with risk factors such as diabetes or immunocompromised state, as it may contribute to malignant otitis externa 1
• Considering alternative causes of illness, such as fungal infections or dermatologic disorders, if symptoms persist despite treatment 1
• Referring to an otolaryngologist if symptoms persist after wick therapy or if complications are suspected 1

It is essential to note that oral antibiotics have limited utility in treating otitis externa, and their use should be reserved for cases where symptoms persist despite topical therapy or where complications are suspected 1. In such cases, oral antibiotics like amoxicillin-clavulanate or ciprofloxacin may be considered. However, the primary approach should focus on optimizing topical treatment and addressing any underlying factors contributing to treatment failure.

From the Research

Next Steps in Treatment for Otitis Externa

The child in question has severe swelling of the external auditory canal that persists after 2 days of therapy with ototopical antibiotic/corticosteroid drops. Considering the provided evidence, the next steps in treatment can be evaluated as follows:

• Insertion of a wick into the external auditory canal: This option is particularly relevant for cases where there is significant swelling of the external auditory canal, as it allows for the direct application of topical medications [ 2 ]. The use of a wick can facilitate the delivery of the medication to the affected area, potentially enhancing the efficacy of the treatment.
• Continuation or adjustment of topical treatment: The evidence suggests that topical treatments alone are effective for uncomplicated acute otitis externa [ 2 ]. However, the persistence of severe swelling after 2 days of treatment may indicate the need for a reassessment of the current topical regimen or the addition of other topical agents.
• Role of oral antibiotics: The use of oral antibiotics is generally reserved for more severe cases or when there are signs of systemic infection [ 3, 4 ]. The decision to prescribe oral antibiotics should be based on a thorough evaluation of the patient's condition and the potential benefits and risks of such treatment.
• Other considerations: The management of otitis externa may also involve the use of pain relief measures, avoidance of further irritation to the ear canal, and follow-up to monitor the resolution of symptoms [ 5, 6 ].

Key Considerations

• The choice of next steps should be guided by the severity of symptoms, the response to initial treatment, and the presence of any complicating factors.
• Topical treatments remain a cornerstone in the management of otitis externa, with the potential for adjustment or escalation based on clinical response.
• Oral antibiotics should be considered judiciously, taking into account the potential for antibiotic resistance and the need for targeted therapy.

Some possible answers based on the information provided are:

• c. Insert a wick into the external auditory canal.
• a. Prescribe an oral antibiotic medication (though this would typically be considered if there were signs of more severe infection or if the patient had not responded to topical treatments and the condition warranted such escalation).
• The provided evidence does not strongly support the immediate initiation of systemic corticosteroids or the irrigation of the external auditory canal with saline as the next step without further consideration of the patient's specific condition and response to initial therapy.