Management of Otitis Externa
Topical antimicrobial preparations should be prescribed as the first-line treatment for uncomplicated acute otitis externa, with appropriate pain management and aural toilet to enhance drug delivery. 1
Diagnosis
- Acute otitis externa (AOE) is defined as diffuse inflammation of the external ear canal with rapid onset (generally within 48 hours) in the past 3 weeks 1, 2
- Key diagnostic features include ear pain (often severe), itching, or fullness, with or without hearing loss, along with tenderness of the tragus, pinna, or both 1
- Nearly 98% of AOE cases in North America are bacterial, with Pseudomonas aeruginosa (20-60%) and Staphylococcus aureus (10-70%) being the most common pathogens 1, 2
Initial Management
Aural Toilet
- Perform aural toilet to remove debris and enhance medication delivery before administering topical therapy 1, 2
- Use gentle suction, dry mopping, or irrigation to clean the ear canal 2
- When the ear canal is obstructed, enhance delivery of topical drops by performing aural toilet, placing a wick, or both 1
Topical Therapy
- Prescribe topical antimicrobial preparations for initial therapy of diffuse, uncomplicated AOE 1
- Effective options include preparations containing:
- Combination products with antibiotics and corticosteroids can help reduce inflammation 6
- For ciprofloxacin otic solution (0.2%), instill contents of one single-dose container into the affected ear twice daily for 7 days 4
- For ofloxacin otic solution, instill 5 drops (pediatric patients 6 months to 13 years) or 10 drops (patients ≥13 years) into the affected ear once daily for 7 days 5
Pain Management
- Assess pain severity and prescribe appropriate analgesics, as pain from AOE can be intense 1, 2
- For mild to moderate pain, use acetaminophen or nonsteroidal anti-inflammatory drugs 2
- For severe pain, consider short-term opioid-containing analgesics for the initial 48-72 hours 2
Special Considerations
Non-Intact Tympanic Membrane
- When the patient has a known or suspected perforation of the tympanic membrane or tympanostomy tube, use only non-ototoxic preparations 1, 2
- Quinolones (ciprofloxacin or ofloxacin) are appropriate choices for patients with non-intact tympanic membranes 2, 4, 5
High-Risk Patients
- Patients with diabetes or immunocompromised states require special consideration as they are susceptible to otomycosis and necrotizing otitis externa 2, 7
- Avoid water irrigation in diabetic or immunocompromised patients due to the risk of malignant otitis externa 8
When to Use Systemic Antibiotics
- Do NOT prescribe systemic antimicrobials as initial therapy for diffuse, uncomplicated AOE 1
- Reserve systemic antibiotics for specific circumstances:
Follow-up and Monitoring
- If the patient fails to respond to the initial therapeutic option within 48-72 hours, reassess to confirm the diagnosis and exclude other causes 1
- Patients should expect improvement within 48-72 hours of initiating appropriate therapy 8
- Complete the full course of therapy even if symptoms resolve early 8
Common Pitfalls to Avoid
- Using antibacterial drops for fungal infections promotes fungal overgrowth 8, 7
- Failure to adequately clean the ear canal before medication application reduces treatment efficacy 2, 8
- Using ototoxic preparations when tympanic membrane integrity is compromised can cause hearing damage 1, 2
- Prolonged use of topical antibiotics may lead to secondary fungal infection (otomycosis) 1, 8
Patient Education
- Instruct patients on proper administration of ear drops to ensure medication reaches infected areas 1, 2
- The solution should be warmed by holding the container in the hands for at least 1 minute to minimize dizziness 4, 5
- The patient should lie with the affected ear upward, and then the solution should be instilled 4
- This position should be maintained for at least 1 minute to facilitate penetration of the drops into the ear canal 4, 5