What is the management for dehiscence of the ear canal?

Management of Ear Canal Dehiscence

Topical antibiotic therapy combined with proper ear canal cleaning is the cornerstone of managing ear canal dehiscence, achieving clinical cure rates of 77-96% compared to only 30-67% with systemic antibiotics. 1

Initial Assessment and Treatment

Cleaning and Debris Removal

• Perform aural toilet to remove inflammatory debris, obstructing cerumen, or foreign objects 2
• Cleaning methods include:
  • Gentle lavage using body-temperature water, saline solution, or hydrogen peroxide
  • Physical removal of debris with suction or dry mop (cotton-tipped applicator with blotting technique)
  • For adequate visualization, use an otoscope with an open head or a binocular otologic microscope 2

Topical Medication

• First-line treatment: Topical antibiotic drops (fluoroquinolones like ciprofloxacin or ofloxacin) 1
• For cases with inflammation, consider antibiotic-corticosteroid combination drops for better outcomes 3
• Apply drops properly to ensure effective delivery:
  • Have patient lie down with affected ear upward
  • Fill ear canal completely with drops
  • Maintain position for 3-5 minutes
  • Use gentle to-and-fro movement of the pinna or tragal pumping to eliminate trapped air 2

Wick Placement

• Place a wick in the ear canal if:
  • Edema prevents drop entry
  • Most of the tympanic membrane cannot be visualized 2
• Use compressed cellulose wick (preferred) or ribbon gauze
• Moisten the wick with aqueous solution before first application of medication
• Do not use simple cotton balls as they can fall apart and remain in the ear canal 2
• The wick may fall out spontaneously once ear canal edema subsides (usually within 24 hours to a few days) 2

Special Considerations

For Diabetic or Immunocompromised Patients

• Avoid aural lavage as it has been implicated as a contributing factor to malignant otitis externa
• Use atraumatic cleaning with aural suctioning under microscopic guidance 2
• Monitor closely for signs of malignant (necrotizing) otitis externa

For Patients with Tympanostomy Tubes

• If ear discharge occurs, topical antibiotic therapy is more effective than oral antibiotics 1
• Place drops in the ear canal twice daily for up to 10 days
• "Pump" the tragus after placing drops to help them enter the ear tube 2
• Remove drainage with cotton-tipped swab dipped in hydrogen peroxide or warm water, a cotton ball, or gentle suction 2

Pain Management

• Assess pain severity using appropriate scales such as the visual analog scale 1
• For mild to moderate pain: acetaminophen or NSAIDs (ibuprofen)
• For more severe pain: consider fixed combination with an opioid
• Administer analgesics at regular intervals rather than as needed for more effective pain control 1

Prevention of Complications

Water Precautions

• Keep the ear dry during treatment 1
• Cover the ear canal opening with cotton saturated with petroleum jelly during bathing or hair washing
• Avoid swimming until symptoms resolve 2, 1

Follow-up Care

• Monitor for:
  • Ear drainage continuing for more than 7 days
  • Frequent recurrence of drainage
  • Excessive wax build-up in the ear canal 2
• Schedule follow-up if symptoms persist despite treatment 1

What to Avoid

• Do not use ear candles (can cause obstruction and hearing loss) 2
• Avoid inserting anything into the ear canal, including cotton-tipped swabs 1
• Do not use Playdoh or silly putty as earplugs 2
• Avoid topical anesthetic drops as they can mask symptoms 1
• Limit use of antibiotic eardrops to no more than 10 days at a time to prevent yeast infections 2

By following this structured approach to managing ear canal dehiscence, clinicians can effectively treat the condition while minimizing complications and improving patient outcomes.