What is the treatment for a red, swollen, hot, and slightly oozing outer ear, possibly indicating an infection like cellulitis?

Treatment of Red, Swollen, Hot, and Oozing Outer Ear

This presentation is consistent with acute otitis externa (AOE) with possible extension to cellulitis of the pinna, and requires topical antimicrobial therapy as first-line treatment, with systemic antibiotics reserved only if infection extends beyond the ear canal. 1

Immediate Assessment

Confirm the diagnosis by checking for:

• Tenderness when pushing the tragus or pulling the pinna (hallmark sign of AOE, often intense and disproportionate to visual findings) 1
• Diffuse ear canal edema, erythema, or both on otoscopy 1
• Rapid onset within 48 hours to 3 weeks 1
• Cellulitis of the pinna and adjacent skin (redness, swelling, warmth extending beyond the ear canal) 1

Assess for high-risk features that would modify treatment:

• Diabetes or immunocompromised status (risk for necrotizing otitis externa) 2, 3
• Age over 58 years 3
• Tympanic membrane perforation or tympanostomy tube 1, 2

First-Line Treatment Approach

1. Aural Toilet (Ear Canal Cleaning)

Perform gentle cleaning before administering drops to ensure medication reaches infected tissues 2, 3, 4:

• Use gentle lavage with body-temperature water, saline, or hydrogen peroxide 2
• For diabetic or immunocompromised patients: avoid irrigation and use only atraumatic suctioning 2, 3
• Remove obstructing cerumen, debris, or foreign objects 2

2. Topical Antimicrobial Therapy

Prescribe topical antibiotic drops targeting Pseudomonas aeruginosa and Staphylococcus aureus (the causative organisms in 98% of AOE cases) 1, 2:

For intact tympanic membrane:

• Ofloxacin 0.3% otic solution (preferred option with once-daily dosing and superior microbiological eradication) 2
• Alternative: Ciprofloxacin 0.2% or neomycin/polymyxin B combinations 3

For perforated tympanic membrane or tympanostomy tubes:

• Use only non-ototoxic quinolone drops (ofloxacin or ciprofloxacin) 1, 2

Treatment duration: 7-10 days (clinical cure rates 65-90%) 3

3. Drug Delivery Enhancement

If significant canal edema prevents drop entry:

• Place a wick in the ear canal to facilitate medication delivery 2
• Instruct patient to lie with affected ear upward, fill canal with drops, and maintain position for 3-5 minutes 2, 3
• Apply gentle to-and-fro movement of the ear or press tragus with in/out movement 2

4. Pain Management

Assess pain severity and prescribe analgesics accordingly 1, 3:

• Mild to moderate pain: acetaminophen or NSAIDs (ibuprofen significantly reduces pain compared to placebo) 1
• Severe pain: consider fixed combination with opioid (oxycodone or hydrocodone) 1
• Inform patient that pain typically improves within 48-72 hours of starting treatment 2, 3

When to Add Systemic Antibiotics

Reserve oral antibiotics for specific circumstances only 2, 4:

• Extension of infection beyond the ear canal (cellulitis of pinna and adjacent skin, as in this case) 2, 4
• Diabetes or immunocompromised status 2, 4
• Topical therapy cannot reach infected area or has failed 2, 4

If systemic antibiotics are indicated for cellulitis extension:

• Target gram-positive organisms (Staphylococcus aureus) and Pseudomonas aeruginosa 1, 5
• Consider anti-pseudomonal coverage given the microbiology of AOE 1, 4

Follow-Up and Treatment Failure

Reassess within 48-72 hours if no improvement 1, 2, 4:

Reasons for treatment failure:

• Inadequate drug delivery due to canal obstruction 4
• Poor adherence to therapy 4
• Fungal co-infection (suspect if white debris with hyphae or "wet newspaper" appearance on otoscopy) 1, 3, 4
• Contact dermatitis from topical agents 4
• Incorrect diagnosis 4

If fungal infection suspected:

• Use topical antifungal therapy and thorough debridement 1, 3, 4
• Avoid antibacterial drops (ineffective and promote fungal overgrowth) 1, 2

Critical Pitfalls to Avoid

• Do NOT use oral antibiotics as initial therapy for uncomplicated AOE (topical therapy is first-line) 2, 4, 5
• Do NOT use ototoxic preparations (aminoglycosides) if tympanic membrane integrity is uncertain 1, 2
• Do NOT fail to remove debris before administering drops (medication won't reach infected tissues) 2, 3
• Do NOT undertreat pain (AOE pain can be severe and requires adequate analgesia) 1, 2
• Do NOT miss fungal infections, especially in diabetic patients or those failing antibacterial therapy 1, 2, 3
• Do NOT use aggressive irrigation in diabetic or immunocompromised patients (risk of necrotizing otitis externa) 2, 3

Patient Instructions

• Keep ear dry during treatment (use earplug or cotton with petroleum jelly when showering) 2
• Continue drops for full 7-10 days even if symptoms improve 2, 3
• Avoid inserting anything into ear canal, including cotton swabs 2
• Return if no improvement within 48-72 hours 2, 3