What is the plan of care for acute external otitis?

Plan of Care for Acute External Otitis

The primary treatment for acute otitis externa (AOE) consists of topical antimicrobial therapy, proper aural toilet to remove debris, and adequate pain management. 1

Initial Assessment and Diagnosis

• Assess for modifying factors that may complicate management, including nonintact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, or prior radiotherapy 2
• Evaluate for pain severity to guide appropriate analgesic treatment 2
• Check for signs of fungal infection (white debris with hyphae for Candida, or "wet newspaper" appearance with black dots for Aspergillus), especially in patients with diabetes or those who fail to respond to antibacterial therapy 2

Treatment Components

1. Aural Toilet

• Clear the ear canal of inflammatory debris, obstructing cerumen, or foreign objects before administering topical medication 2
• Cleaning methods include:
  • Gentle lavage with body-temperature water, saline, or hydrogen peroxide
  • Suction or dry mopping (blotting with cotton-tipped applicator)
  • For diabetic or immunocompromised patients, avoid irrigation and use atraumatic cleaning with aural suctioning 2

2. Topical Antimicrobial Therapy

• Prescribe topical antimicrobial preparations effective against common pathogens (Pseudomonas aeruginosa and Staphylococcus aureus) 1, 3
• For intact tympanic membrane:
  • Ofloxacin 0.3% otic solution: 10 drops once daily for 7 days (adults and children ≥13 years) or 5 drops once daily for 7 days (children 6 months to 13 years) 4
  • Other effective options include aminoglycosides, polymyxin B, or quinolones with or without corticosteroids 3
• For perforated tympanic membrane or tympanostomy tubes:
  • Use non-ototoxic preparations only, such as quinolone drops (ofloxacin, ciprofloxacin) 2, 1

3. Ear Canal Wick

• Place a wick in the ear canal if edema prevents drop entry or if most of the tympanic membrane cannot be visualized 2
• Use compressed cellulose (preferred) or ribbon gauze, not cotton balls 2
• The wick may fall out spontaneously as inflammation resolves, or can be removed once ear canal edema subsides (usually within 24 hours to a few days) 2

4. Pain Management

• Prescribe analgesics based on pain severity 2
• Inform patients that pain typically improves within 48-72 hours of starting treatment 1, 5

5. Patient Education

• Instruct on proper administration of ear drops:
  • Warm drops by holding bottle in hand for 1-2 minutes to prevent dizziness 2, 4
  • Lie with affected ear upward and fill ear canal with drops 2
  • Maintain position for 3-5 minutes to allow drops to penetrate 2
  • Use gentle to-and-fro movement of the pinna or press the tragus to help drops reach their destination 2
• Keep the ear dry during treatment 2
• Avoid self-cleaning the ear due to tenderness 2
• Complete the full course of therapy even if symptoms resolve early 1

Special Considerations

For Diabetic or Immunocompromised Patients

• Monitor carefully for signs of necrotizing otitis externa 1
• Consider adding systemic antibiotics 1
• Avoid ear canal irrigation 2

For Suspected Fungal Infection

• Use topical antifungal therapy and debridement 1
• Avoid antibacterial drops that may promote fungal overgrowth 2

For Nonintact Tympanic Membrane

• Use only non-ototoxic topical preparations (e.g., quinolones) 2, 1

When to Use Systemic Antibiotics

• Reserve oral antibiotics for specific circumstances 1:
  • Extension of infection beyond the ear canal
  • Patients with diabetes or immunocompromised status
  • When topical therapy cannot reach the infected area or has failed

Expected Course and Follow-up

• Symptoms typically improve within 48-72 hours and resolve after 6-7 days 5
• Patients with persisting symptoms beyond two weeks should be considered treatment failures and alternative management initiated 6

Common Pitfalls to Avoid

• Overuse of oral antibiotics for uncomplicated cases 1
• Using ototoxic preparations when tympanic membrane integrity is compromised 1
• Inadequate pain management 1
• Failure to remove debris before administering drops 1
• Missing fungal infections, especially in patients with diabetes 1