How should I document a right‑ear otitis externa encounter, covering chief complaint, history of present illness, past medical history, medications, allergies, review of systems, physical exam, assessment and management plan?

Documentation of Right-Ear Otitis Externa

For a right-ear otitis externa encounter, document rapid-onset ear pain with tragal tenderness, perform aural toilet before prescribing topical fluoroquinolone drops, and provide appropriate analgesia with reassessment in 48–72 hours.

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Chief Complaint

• Document the primary symptom: "Right ear pain" with onset timing (typically <48 hours for acute otitis externa) 1
• Record associated symptoms: itching, fullness, hearing changes, or discharge 1
• Note any water exposure (swimming, showering) or recent ear canal trauma (cotton swabs, hearing aids) 1

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History of Present Illness

Symptom Characteristics

• Pain quality and severity: Describe as sharp, throbbing, or constant; rate severity on 0–10 scale 1
• Timing: Rapid onset within 48 hours is characteristic 1
• Aggravating factors: Pain with tragus/pinna manipulation, chewing, or lying on affected side 2
• Associated symptoms: Pruritus, aural fullness, hearing reduction, or otorrhea 1, 3

Precipitating Events

• Recent swimming or water exposure 4, 3
• Ear canal manipulation (cotton swabs, fingernails, hearing aids) 4
• Recent upper respiratory infection 1
• Use of ear plugs or hearing aids 2

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Past Medical History

Critical Risk Factors to Document

• Diabetes mellitus (including glycemic control status) – increases risk of necrotizing otitis externa and otomycosis 1, 5, 6
• Immunocompromised state (HIV, transplant recipient, chemotherapy, chronic steroid use) 1, 6, 7
• Prior ear surgery or tympanostomy tubes 1, 5
• History of radiation therapy to head/neck 1, 5, 7
• Dermatologic conditions (eczema, psoriasis, seborrheic dermatitis) affecting the ear 2, 3
• Previous episodes of otitis externa (frequency and treatment response) 4, 3

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Medications

• List all current medications, particularly:
  • Topical ear preparations (current or recent) 2
  • Immunosuppressive agents 6, 7
  • Chemotherapeutic agents 7
  • Chronic corticosteroids 6, 7

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Allergies

• Neomycin allergy – critical because neomycin causes contact sensitivity in 13–30% of patients with chronic otitis externa 1
• Other topical antibiotic allergies (polymyxin B, bacitracin) 1
• Fluoroquinolone allergy 1
• Hydrocortisone or other steroid allergies 1

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Review of Systems

Ear-Specific

• Otalgia (right ear) 1, 3
• Otorrhea (describe color, consistency) 1, 3
• Pruritus 1, 3
• Hearing loss or aural fullness 1, 3
• Tinnitus 3

Red Flags Requiring Immediate Attention

• Facial weakness or paralysis (cranial nerve VII involvement) 2, 6
• Severe headache 6
• Fever 6
• Periauricular swelling or cellulitis 1, 5
• Neurologic deficits 6
• Pain out of proportion to examination findings 6

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Physical Examination

Inspection

• External ear: Erythema, edema, or lesions of pinna 1, 3
• Periauricular area: Swelling, erythema, or lymphadenopathy 1

Palpation

• Tragal tenderness: Apply gentle pressure to tragus – intense tenderness is pathognomonic for otitis externa 1, 3
• Pinna manipulation: Pull pinna superiorly and posteriorly – pain indicates external canal involvement 1, 3
• Periauricular lymph nodes: Document presence, size, and tenderness 1

Otoscopy

• Canal findings: Erythema, edema (grade severity), debris, cerumen, or discharge 1, 3
• Tympanic membrane status: Intact vs. perforated, mobility (pneumatic otoscopy when possible), presence of tympanostomy tubes 1, 5
• Visualization: Document if TM fully visible or obscured by edema/debris 1, 5
• Granulation tissue: Presence suggests possible necrotizing otitis externa in high-risk patients 6

Neurologic Examination (in high-risk patients)

• Cranial nerve function, especially facial nerve (CN VII) 6

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Assessment

Primary Diagnosis

• Acute otitis externa, right ear 1, 3

Modifying Factors (Document if Present)

• Intact vs. non-intact tympanic membrane 1, 5
• Presence of tympanostomy tubes 1, 5
• Diabetes mellitus or immunocompromised state 1, 5, 6
• Prior ear surgery or radiation 1, 5
• Severe canal edema preventing drop entry 1, 5

Differential Diagnoses to Exclude

• Necrotizing (malignant) otitis externa – suspect in diabetic/immunocompromised patients with severe pain, granulation tissue, or cranial nerve involvement 6
• Chronic suppurative otitis media – painless otorrhea through TM perforation without tragal tenderness 1
• Acute otitis media with perforation 1
• Contact dermatitis – from topical agents, especially neomycin 2, 1
• Fungal otitis externa (otomycosis) – white fuzzy exudate with pruritus 1
• Furunculosis – localized pustular lesion in outer third of canal 2
• Herpes zoster oticus – vesicles with facial paralysis 2

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Management Plan

1. Aural Toilet (Essential First Step)

• Remove debris, cerumen, and inflammatory material before any medication to ensure drops reach infected tissue 1, 5
• Method selection:
  • Standard patients: Gentle suction, dry mopping, or irrigation with body-temperature water/saline/hydrogen peroxide 1, 5
  • Diabetic or immunocompromised patients: Atraumatic suction under microscopy only – avoid irrigation (can precipitate necrotizing otitis externa) 1, 5

2. Wick Placement (If Indicated)

• Place compressed cellulose wick if severe canal edema prevents drop entry or TM cannot be visualized 1, 5
• Instruct patient to apply drops to wick; remove wick after 24–48 hours when edema subsides 1

3. Topical Antimicrobial Therapy (First-Line)

When Tympanic Membrane Status Is Uncertain or Compromised

• Prescribe non-ototoxic fluoroquinolone drops only 1, 5:
  • Ofloxacin 0.3% otic solution: 5–10 drops twice daily for 7 days 1, 5
  • Ciprofloxacin 0.2% otic solution: 4 drops twice daily for 7 days 1
• Avoid aminoglycoside-containing preparations (neomycin/polymyxin B) due to ototoxicity risk 1, 5

When Tympanic Membrane Is Intact

• Any FDA-approved topical preparation is acceptable (65–90% cure rate within 7–10 days) 1, 5:
  • Ofloxacin 0.3% 1, 5
  • Ciprofloxacin 0.2% with or without dexamethasone 1
  • Neomycin/polymyxin B/hydrocortisone (if no neomycin allergy or eczema history) 1, 3
  • Acetic acid 2% with hydrocortisone 4, 3

Drop Administration Instructions

• Warm bottle in hands for 1–2 minutes 1
• Lie with affected ear upward 1, 5
• Fill ear canal completely with drops 1, 5
• Remain in position for 3–5 minutes (use timer) 1, 5
• Apply gentle tragal pumping or pinna movement to eliminate trapped air 1, 5
• Have another person administer drops if possible (improves adherence) 1

Treatment Duration

• Minimum 7 days, even if symptoms resolve earlier (prevents relapse) 1, 5
• If symptoms persist beyond 7 days, continue until resolution (maximum 14 days total) 1

4. Pain Management

Mild-to-Moderate Pain

• Acetaminophen 650–1000 mg every 6 hours 1
• Ibuprofen 400–600 mg every 6 hours 1

Severe Pain

• Short-term opioid-containing analgesics for first 48–72 hours 1, 5
• Reassure patient that pain typically improves within 48–72 hours of starting topical therapy 1, 5

Avoid

• Do not prescribe topical anesthetic drops (benzocaine) – not FDA-approved for active infection and may mask treatment failure 1

5. Systemic Antibiotics (Reserved Indications Only)

Oral antibiotics are NOT indicated for uncomplicated otitis externa 1, 5

Prescribe Systemic Antibiotics Only When:

• Infection extends beyond ear canal (periauricular cellulitis/swelling) 1, 5
• Patient has diabetes mellitus or immunocompromised state 1, 5, 6
• Severe canal edema prevents adequate topical delivery despite wick placement 1, 5
• No improvement after 48–72 hours of appropriate topical therapy 1, 5

Recommended Systemic Agent

• Ciprofloxacin 500 mg PO twice daily for 7–10 days (covers Pseudomonas aeruginosa and Staphylococcus aureus, which cause ~98% of cases) 1

6. Activity Restrictions and Patient Education

• Keep ear dry during treatment – cover canal with earplug or petroleum jelly-coated cotton before showering 1, 5
• Avoid swimming until infection resolves 1, 5
• Do not insert cotton swabs or any objects into ear canal 1, 5
• Complete full 7-day course even if symptoms improve 1, 5
• If patient tastes drops, notify physician immediately (indicates TM perforation) 1

7. Follow-Up and Reassessment

• Reassess within 48–72 hours if no improvement 1, 5
• Return if symptoms persist beyond 2 weeks 1

Common Causes of Treatment Failure

• Inadequate drug delivery (canal obstruction, poor adherence) 1
• Allergic contact dermatitis from topical agents (especially neomycin or hydrocortisone) 2, 1
• Fungal co-infection (otomycosis) 1, 5
• Incorrect diagnosis (chronic suppurative otitis media, necrotizing otitis externa) 1, 6

8. Special Considerations for High-Risk Patients

Diabetic or Immunocompromised Patients

• Monitor closely for necrotizing otitis externa (severe pain, granulation tissue, cranial nerve involvement) 1, 6
• Avoid ear canal irrigation – use atraumatic suction only 1, 5
• Consider systemic antibiotics even for seemingly uncomplicated cases 1, 5
• Lower threshold for ENT referral 6

Suspected Fungal Infection (Otomycosis)

• White fuzzy exudate with pruritus suggests Aspergillus 1
• Treatment: Thorough debridement + topical antifungal (clotrimazole 1% or boric acid 2%) 3–4 times daily for 7–10 days 1
• Avoid antibacterial drops that promote fungal overgrowth 1, 5

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Common Pitfalls to Avoid

• Prescribing oral antibiotics for uncomplicated cases (occurs in 20–40% of patients inappropriately) 1
• Using ototoxic preparations when TM integrity is uncertain 1, 5
• Skipping aural toilet before drop administration 1, 5
• Inadequate pain management 1, 5
• Irrigating ear canal in diabetic/immunocompromised patients 1, 5
• Missing fungal infections in high-risk patients 1, 5
• Prescribing neomycin-containing drops to patients with eczema or contact dermatitis history 1