Acute Otitis Externa: Immediate Management
This 40-year-old man with fever and sharp left ear pain most likely has acute otitis externa, and you should begin with aural toilet followed by topical fluoroquinolone ear drops plus oral analgesics.
Confirm the Diagnosis
Perform tragal/pinna tenderness testing – the hallmark of acute otitis externa is intense pain when you pull the pinna or press the tragus, which distinguishes it from otitis media 1. This finding is present in nearly all cases and is the single most reliable diagnostic sign 2.
Examine the ear canal with otoscopy looking for:
- Diffuse canal erythema and edema 2
- Wet debris or purulent discharge 2
- Whether you can visualize the entire tympanic membrane (if not, severe edema may require wick placement) 1
Assess for high-risk features that change management:
- Diabetes or immunocompromised state (requires systemic antibiotics even for seemingly uncomplicated cases) 1
- Extension beyond the canal – look for periauricular swelling or cellulitis (mandates oral antibiotics) 1
- Fever with severe pain raises concern for necrotizing otitis externa in diabetics 2, 3
First-Line Treatment Algorithm
Step 1: Aural Toilet (Essential Pre-Treatment)
Remove all debris, cerumen, and inflammatory material using gentle suction, dry mopping, or body-temperature irrigation before any drops 1. Medication cannot penetrate debris to reach infected tissue 1. If the patient is diabetic or immunocompromised, use only atraumatic suction under microscopy – never irrigate, as this can trigger necrotizing otitis externa 1.
Step 2: Topical Antibiotic Selection
Use ofloxacin 0.3% or ciprofloxacin 0.2% ear drops because tympanic membrane integrity is uncertain in this acute presentation with fever 1. These non-ototoxic fluoroquinolones are safe even if a perforation exists 1. Avoid aminoglycoside-containing drops (neomycin/polymyxin B) when you cannot confirm the tympanic membrane is intact 1.
Dosing: Instill drops to fill the canal completely, have the patient lie with affected ear upward for 3–5 minutes, and pump the tragus gently to eliminate trapped air 1. Prescribe for 7 days minimum even if symptoms resolve earlier 1.
Step 3: Aggressive Pain Management
This patient requires opioid-containing analgesics for the first 48–72 hours because otitis externa pain is often severe and disproportionate to visual findings 1, 4. Combine with ibuprofen 400–600 mg every 6 hours 1. Reassure the patient that pain typically improves within 48–72 hours of starting drops 1.
When to Add Oral Antibiotics
Add ciprofloxacin 500 mg twice daily if any of the following are present 1:
- Fever with periauricular swelling or cellulitis (extension beyond the canal)
- Diabetes mellitus or immunocompromised status
- Severe canal edema preventing adequate topical delivery despite wick placement
- No improvement after 48–72 hours of appropriate topical therapy
The presence of fever in this case warrants careful assessment for extension beyond the canal 1. If you see any periauricular swelling, systemic antibiotics are mandatory 1.
Critical Pitfalls to Avoid
Do not prescribe oral antibiotics alone – topical therapy achieves 77–96% cure rates versus only 30–67% for oral antibiotics, yet 20–40% of patients inappropriately receive oral-only treatment 1.
Do not skip aural toilet – this is the most common reason for treatment failure because medication cannot reach the infection through debris 1.
Do not use aminoglycoside drops when tympanic membrane integrity is uncertain, as they cause ototoxicity if a perforation exists 1.
In diabetic patients, never irrigate the ear canal – use only atraumatic suction, as irrigation can precipitate life-threatening necrotizing otitis externa 1.
Reassessment
See the patient again in 48–72 hours if symptoms do not improve 1. Common reasons for failure include inadequate drug delivery (obstruction, poor adherence), fungal co-infection (especially in diabetics), allergic contact dermatitis from neomycin, or misdiagnosis (chronic suppurative otitis media, necrotizing otitis externa) 1.