Conservative Treatment for Otitis Externa
The cornerstone of conservative treatment for otitis externa includes topical therapy with fluoroquinolone preparations with corticosteroids, adequate pain management, and proper ear canal cleaning, while avoiding systemic antibiotics for uncomplicated cases. 1
Diagnosis Confirmation
- Confirm diagnosis by identifying:
- Rapid onset (within 48 hours) in past 3 weeks
- Symptoms: otalgia, itching, fullness, with/without hearing loss
- Signs: tenderness of tragus/pinna, ear canal edema, erythema 1
- Distinguish from acute otitis media by checking tympanic membrane mobility (good mobility in otitis externa, limited in otitis media) 2
Topical Therapy
- First-line treatment: Topical fluoroquinolone preparation with corticosteroid
- Example: ciprofloxacin 0.3%/dexamethasone 0.1% (3-4 drops twice daily for 7 days) 1
- Continue treatment for at least 7 days, even if symptoms improve sooner 2
- If tympanic membrane is perforated or tympanostomy tubes present:
- Use only non-ototoxic preparations (fluoroquinolones)
- Avoid aminoglycoside-containing products (neomycin/polymyxin B) 1
Pain Management
- Pain from otitis externa can be intense due to proximity of periosteum to ear canal skin 2
- Treat based on severity:
- Mild to moderate pain: Acetaminophen or NSAIDs
- Severe pain: Combination analgesics with short-term opioids (48-72 hours) 1
- Administer at fixed intervals rather than as needed for better pain control 2
- Topical anesthetic drops (e.g., benzocaine) are not FDA-approved for safety/effectiveness and should not be used if tympanic membrane integrity is uncertain 2
Ear Canal Care
- Aural toilet (cleaning) is essential for effective treatment:
- Gently remove debris that blocks medication delivery
- Methods include gentle lavage with body-temperature water/saline, suction, or dry mop technique 2
- For obstructed ear canals:
- Place a wick (preferably compressed cellulose) to enhance drug delivery
- Wick expands when moistened, facilitating medication penetration
- Remove once ear canal edema subsides (typically within 24-72 hours) 2
- Proper drop administration:
- Lie with affected ear up
- Fill ear canal with prescribed drops
- Remain in position for 3-5 minutes
- Use gentle to-and-fro movement of pinna or tragal pumping to help drops penetrate 2
Avoiding Systemic Antibiotics
- Do not prescribe systemic antibiotics for uncomplicated otitis externa 2, 1
- Consider systemic antibiotics only if:
- Infection extends beyond ear canal
- Patient has diabetes or is immunocompromised
- Concurrent condition requires systemic treatment 1
Follow-up and Reassessment
- If no improvement after 48-72 hours:
- Reassess diagnosis
- Check for proper medication administration
- Consider fungal infection (otomycosis)
- Consider alternative topical therapy 1
- Most patients should show significant improvement within 48-72 hours, though complete resolution may take up to 2 weeks 1
Prevention Measures
- Keep ears dry
- Consider acidifying ear drops (2% acetic acid) after swimming if recurrent episodes occur 3
- Avoid inserting foreign objects into ear canal, including cotton-tipped swabs 1
- Use ear protection (earplug or cotton with petroleum jelly) when showering or washing hair 2
Cautions and Special Considerations
- Avoid aggressive ear cleaning that could traumatize the canal
- In diabetic or immunocompromised patients, avoid ear canal lavage as it may contribute to malignant otitis externa 2
- For patients with suspected fungal infection, consider topical antifungal treatment 1
- Consider referral to otolaryngologist if symptoms persist despite appropriate therapy or if severe inflammation extends beyond ear canal 1