What is the treatment for red, painful ears with a feeling of heat, possibly indicating otitis externa or otitis media?

Red, Painful, Hot Ears: Diagnosis and Treatment

This presentation is most consistent with acute otitis externa (AOE), and treatment should consist of topical antibiotic drops (with or without corticosteroids) plus adequate analgesia, while avoiding oral antibiotics unless infection extends beyond the ear canal. 1, 2

Key Diagnostic Features

The hallmark finding that distinguishes otitis externa from other conditions is intense tenderness when manipulating the tragus or pinna, often disproportionate to visual findings on examination. 1, 2 This tragal tenderness is the classic sign that confirms the diagnosis and differentiates it from otitis media, where the pain is deeper and manipulation of the external ear is not particularly tender. 2

What to Look For on Examination:

• Erythema and swelling of the ear canal with variable discharge 3, 4
• Pain with tragal or pinna manipulation (pathognomonic for otitis externa) 1, 2
• Otoscopic findings: Look for canal edema, erythema, debris, and assess if the tympanic membrane is visible and intact 1
• Check for extension beyond the canal: Periauricular cellulitis, lymphadenopathy, or systemic signs would indicate need for oral antibiotics 2, 5, 6

Critical Differential Diagnoses to Exclude:

• Furunculosis: Localized pustular lesion in outer third of canal with focal tenderness 2
• Herpes zoster oticus (Ramsay Hunt syndrome): Vesicles on external canal and posterior auricle 2
• Contact dermatitis or eczema: Chronic pruritus, scaling, lichenification without acute infection signs 7
• Referred pain: Temporomandibular joint syndrome or upper aerodigestive malignancies, especially in older adults with tobacco/alcohol use 2

Treatment Algorithm

Step 1: Aural Toilet (Essential First Step)

Thoroughly cleanse the ear canal using suction, dry mopping, or gentle removal of debris and obstructing cerumen—but avoid flushing/irrigation which can worsen the condition. 1, 3 This step is critical because topical medications cannot penetrate through debris and discharge. 1

Step 2: Topical Antimicrobial Therapy (Primary Treatment)

Prescribe topical antibiotic drops targeting Pseudomonas aeruginosa (20-60% of cases) and Staphylococcus aureus (10-70% of cases), the two dominant pathogens in AOE. 1, 4, 6

Effective topical options include:

• Fluoroquinolone drops (ofloxacin, ciprofloxacin) with or without corticosteroids 6
• Polymyxin B combinations 6
• Aminoglycosides (if tympanic membrane is intact) 6
• Acetic acid 2% with hydrocortisone for mild cases and prophylaxis 3, 6

Duration: 7-10 days 6

The addition of corticosteroids reduces swelling, erythema, and secretions, improving drug delivery and patient comfort. 1, 5 Topical therapy delivers antimicrobial concentrations 100-1000 times higher than systemic antibiotics and avoids selecting for resistant organisms throughout the body. 1, 2

If the canal is severely edematous and occluded, insert a wick to facilitate medication delivery. 1

Step 3: Analgesia (Critical Component)

Provide adequate pain relief as ear pain from otitis externa can be severe due to proximity of the highly sensitive periosteum. 1, 2 Use NSAIDs or acetaminophen; consider short-term opioids for severe pain. 1

Step 4: When to Use Oral Antibiotics (Limited Indications)

Oral antibiotics are NOT routinely indicated for uncomplicated AOE and have limited utility. 1 Despite this, 20-40% of patients inappropriately receive oral antibiotics, which are usually inactive against the causative organisms and promote resistance. 1

Reserve oral antibiotics for:

• Extension beyond the ear canal (periauricular cellulitis, lymphadenopathy) 2, 5, 6
• Immunocompromised patients 2, 5, 6
• Poorly controlled diabetes mellitus 5, 6
• Suspected necrotizing (malignant) otitis externa 2, 5

When oral antibiotics are needed, choose agents active against Pseudomonas and Staphylococcus (e.g., fluoroquinolones). 1

Reassessment if No Improvement in 48-72 Hours

If symptoms persist or worsen, consider: 2, 7

• Inadequate aural toilet or drug delivery (repeat cleaning, consider wick placement) 2, 7
• Fungal infection (Aspergillus or Candida), especially after antibiotic treatment—requires antifungal therapy 1, 4
• Contact dermatitis from topical medications, particularly neomycin (affects 13-30% of chronic cases)—switch to non-ototoxic quinolone 7
• Incorrect diagnosis: Eczema, seborrheic dermatitis, or referred pain 2, 7
• Necrotizing otitis externa in diabetic or immunocompromised patients—requires urgent imaging and IV antibiotics 2, 5

Prevention Strategies

For patients with recurrent episodes:

• Acidifying drops (2% acetic acid) after swimming or water exposure 1, 3
• Dry ear canals with hair dryer on low setting 1, 3
• Avoid trauma to the canal (no cotton swabs, aggressive cleaning) 1, 3, 6
• Remove obstructing cerumen prophylactically 1
• Ear plugs while swimming 1

Critical Pitfalls to Avoid

• Do not prescribe oral antibiotics for uncomplicated AOE—they are ineffective against the causative organisms and promote resistance 1
• Do not confuse with otitis media—tragal tenderness is present in externa but not media 2
• Do not miss referred pain from serious conditions like malignancy, especially in older adults with risk factors 2
• Do not overlook necrotizing otitis externa in diabetic or immunocompromised patients—this is life-threatening and requires aggressive treatment 2, 5
• Do not use aminoglycosides if tympanic membrane perforation is suspected—they are ototoxic 6