How to treat otitis externa when impacted cerumen is present?

From the Guidelines

When treating otitis externa with impacted cerumen present, the first step is to carefully remove the cerumen to allow for effective treatment of the infection, as recommended by the most recent clinical practice guidelines 1. The removal of cerumen is essential because it acts as a barrier preventing topical medications from reaching the infected epithelium, while also potentially harboring pathogens that can perpetuate the infection. To remove the cerumen, begin with gentle ear irrigation using body-temperature water or saline, or use cerumenolytic drops such as docusate sodium, hydrogen peroxide 3%, or carbamide peroxide to soften the wax before removal, as suggested by studies on cerumen impaction treatment 1. Manual removal with suction or curettes should be performed by healthcare professionals to avoid trauma to the ear canal. Some key points to consider when treating otitis externa with impacted cerumen include:

• The importance of careful cerumen removal to allow for effective treatment of the infection
• The use of gentle ear irrigation or cerumenolytic drops to soften the wax before removal
• The need for manual removal to be performed by healthcare professionals to avoid trauma to the ear canal
• The treatment of the underlying otitis externa with topical antibiotic drops, such as ciprofloxacin 0.3% with dexamethasone 0.1% or ofloxacin 0.3%, applying 3-4 drops to the affected ear(s) three times daily for 7-10 days
• The consideration of combination antibiotic-steroid preparations like neomycin-polymyxin B-hydrocortisone for more severe infections
• The importance of keeping the ear dry during treatment by avoiding swimming and using earplugs during showers
• The need for patients to complete the full course of treatment even if symptoms improve quickly to prevent recurrence. It is also important to note that some patients may be at increased risk for complications from cerumen impaction, such as elderly adults or developmentally delayed patients, and may require closer monitoring and more aggressive treatment, as highlighted in the clinical practice guidelines 1.

From the Research

Treatment of Otitis Externa with Impacted Cerumen

When treating otitis externa with impacted cerumen, it is essential to consider the following steps:

• Remove the impacted cerumen to allow for proper examination and treatment of the ear canal 2
• Use topical treatments, such as ear drops, which have been shown to be effective in treating uncomplicated acute otitis externa 3
• Consider the use of ceruminolytic agents to help dissolve the impacted cerumen, followed by irrigation 2
• Avoid using cotton swabs or ear candles, as they can push the cerumen further into the ear canal and cause more harm 2

Treatment Options for Otitis Externa

The following treatment options are available for otitis externa:

• Topical antimicrobials containing steroids, which have been shown to be effective in treating acute otitis externa 3
• Acetic acid, which can be used as an alternative to antibiotic/steroid drops, but may be less effective in some cases 3
• Steroid-only drops, although the evidence for their use is limited and more research is needed 3
• Systemic antibiotics, which are only necessary in severe cases or when there are complications such as perichondritis or lymphadenitis 4, 5

Referral to an Otolaryngologist

Referral to an otolaryngologist may be necessary in the following situations:

• If treatment with a ceruminolytic agent followed by irrigation is ineffective 2
• If manual removal of the impacted cerumen is not possible 2
• If the patient develops severe pain or has vertigo during irrigation 2
• If hearing loss is still present after the cerumen has been removed 2