What is the treatment for a patient with suspected skin infection, secondary lymphadenopathy, and possible outer ear canal infection?

Management of Suspected Skin Infection with Lymphadenopathy and Possible Otitis Externa

For this 66-year-old patient with suspected skin infection, secondary lymphadenopathy, and possible outer ear canal infection, topical fluoroquinolone ear drops should be used as first-line therapy for the ear canal infection, while amoxicillin-clavulanate is appropriate for the suspected skin infection with lymphadenopathy. 1, 2

SOAP Note

Subjective

• 66-year-old male with hearing aid use
• Reports swelling underneath left ear that has increased over 4-5 days
• Very painful to touch
• Unable to insert hearing aid due to swelling
• Concurrent diarrhea for same duration
• No scratching or known bug bites
• No fever

Objective

• Left cervical lymphadenopathy
• Signs consistent with possible outer ear canal infection

Assessment

1. Left cervical lymphadenopathy likely secondary to skin infection
2. Possible otitis externa (outer ear canal infection)
3. Concurrent diarrhea (possibly related to infection)

Plan

1. For Otitis Externa

• First-line treatment: Fluoroquinolone ear drops (e.g., ciprofloxacin 0.2% or ofloxacin 0.3%) twice daily for 7 days 1

  • Fluoroquinolones are preferred over polysporin drops due to higher cure rates (77-96%) and non-ototoxic properties 1
  • Complete the full 7-day course even if symptoms improve earlier 1

• Pain management:

  • Acetaminophen or NSAIDs for pain relief until infection is controlled 1

• Patient education:

  • Avoid inserting cotton-tipped swabs into ear canal 1
  • Keep ear canal dry 1
  • Temporarily discontinue hearing aid use until infection resolves 1

2. For Skin Infection with Lymphadenopathy

• Amoxicillin-clavulanate (Amoxiclav) orally for 7-10 days 1, 2

  • Appropriate for skin infections with secondary lymphadenopathy
  • Covers common skin pathogens including S. aureus

• Diagnostic testing:

  • Ultrasound of affected area (today if possible, otherwise tomorrow)
  • Monitor for abscess formation which may require drainage

• Supportive care:

  • Increase fluid intake
  • Avoid touching or squeezing the lymph node

3. Follow-up

• Return if increased swelling, abscess formation, increased redness, or worsening pain occurs
• Return if symptoms do not improve within 48-72 hours of starting treatment
• Follow-up appointment in one week to assess response to treatment

Evidence-Based Rationale

Otitis Externa Management

The American Academy of Otolaryngology-Head and Neck Surgery recommends topical antibiotic preparations, particularly fluoroquinolones, as first-line therapy for uncomplicated otitis externa 1. Topical treatment is preferred over systemic antibiotics for localized ear infections, as systemic medications can unnecessarily increase treatment costs and side effects 3.

Systemic Antibiotics for Skin Infection

Systemic antibiotics are indicated when infection extends beyond the ear canal, as is likely the case with this patient's lymphadenopathy 1. Amoxicillin-clavulanate provides appropriate coverage for skin infections that may be causing the lymphadenopathy 2.

Important Considerations

• Avoid systemic antibiotics for uncomplicated otitis externa alone - The evidence strongly recommends against prescribing systemic antibiotics as initial therapy for uncomplicated otitis externa 1, 3

• Complete the full course of antibiotics - Discontinuing treatment prematurely can lead to incomplete resolution and potential recurrence 1

• Monitor for complications - Patients with diabetes or who are immunocompromised are at higher risk for severe infections and complications such as malignant (necrotizing) otitis externa 1

• Consider fungal infection - If bacterial treatment fails, consider fungal otitis externa (otomycosis), which would require antifungal treatment 1, 4