What is the management for otitis externa?

Management of Otitis Externa

The first-line treatment for acute otitis externa is topical antimicrobial therapy with aural toilet, delivering medication concentrations 100-1000 times higher than systemic therapy while effectively targeting common pathogens like Pseudomonas aeruginosa and Staphylococcus aureus. 1, 2

Initial Assessment and Treatment

• Assess for modifying factors that may complicate management, including nonintact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, or prior radiotherapy 1
• Evaluate pain severity to guide appropriate analgesic treatment, as pain typically improves within 48-72 hours of starting appropriate therapy 1, 3
• Clear the ear canal of inflammatory debris, obstructing cerumen, or foreign objects before administering topical medication to ensure medication reaches infected tissues 1, 2
• Cleaning methods include gentle lavage with body-temperature water, saline, or hydrogen peroxide, or atraumatic cleaning with aural suctioning for diabetic or immunocompromised patients 1, 3

Topical Antimicrobial Therapy

• Prescribe topical antimicrobial preparations effective against common pathogens such as Pseudomonas aeruginosa and Staphylococcus aureus 1, 2
• For intact tympanic membrane, use ofloxacin 0.3% otic solution once daily for 7 days (5 drops for children 6 months to 13 years, 10 drops for patients 13 years and older) 4, 5
• Alternatively, use ciprofloxacin 0.2% otic solution twice daily for 7 days 6
• For perforated tympanic membrane or tympanostomy tubes, use only non-ototoxic preparations such as quinolone drops (ciprofloxacin or ofloxacin) 1, 2
• Place a wick in the ear canal if edema prevents drop entry or if most of the tympanic membrane cannot be visualized 1, 2

Proper Administration of Ear Drops

• Warm the solution by holding the bottle in hand for 1-2 minutes to avoid dizziness from instilling cold solution 4, 6
• Have the patient lie with the affected ear upward and instill enough drops to fill the ear canal 7
• Maintain this position for 3-5 minutes to facilitate penetration of drops into the ear canal 7
• Apply gentle to-and-fro movement of the ear or press with an in/out movement on the tragus to help drops penetrate 7

Pain Management

• Prescribe appropriate analgesics based on pain severity, as pain typically improves within 48-72 hours of starting treatment 1, 3
• For severe pain, consider short-term opioid-containing analgesics for the initial 48-72 hour period 2

Duration of Treatment

• Continue eardrops for at least 7 days, even if symptoms improve sooner, to prevent relapse of infection 7, 5
• If symptoms persist beyond 7 days, notify the doctor and continue the drops until symptoms resolve for a maximum of 7 additional days 7

Special Considerations

For Diabetic or Immunocompromised Patients

• Monitor carefully for signs of necrotizing otitis externa 1, 3
• Consider adding systemic antibiotics 1, 3
• Avoid ear canal irrigation; use atraumatic cleaning with aural suctioning instead 1

For Suspected Fungal Infection

• Use topical antifungal therapy and debridement 1, 3
• Avoid antibacterial drops that may promote fungal overgrowth 1, 3

When to Use Systemic Antibiotics

• Reserve oral antibiotics for specific circumstances: 1, 3, 2
  • Extension of infection beyond the ear canal
  • Patients with diabetes or immunocompromised status
  • When topical therapy cannot reach the infected area or has failed

Activity Restrictions and Precautions

• Avoid scratching or touching the ear and do not insert anything into the ear canal, including cotton-tipped swabs 7
• Cover the opening of ear canal with an earplug or cotton (with petroleum jelly) prior to showering or hair washing to minimize water entry 7
• Consult with doctor regarding swimming or other water activities during or soon after infection 7

Common Pitfalls to Avoid

• Overuse of oral antibiotics for uncomplicated cases 1, 3
• Using ototoxic preparations when tympanic membrane integrity is compromised 1, 2
• Inadequate pain management 1, 3
• Failure to remove debris before administering drops 1, 2
• Missing fungal infections, especially in patients with diabetes 1, 3

Follow-up and Treatment Failure

• Reassess patients within 48-72 hours if no improvement is seen 3
• Reasons for treatment failure may include inadequate drug delivery due to canal obstruction, poor adherence to therapy, incorrect diagnosis, fungal infection, or contact dermatitis from topical agents 3
• If symptoms persist beyond two weeks, consider treatment failure and initiate alternative management 8