Otitis externa
Background
- Inflammation of the external auditory canal (EAC), often due to bacterial infection
- Common in all age groups, but in the US commonly present in childhood [1]
- In rare cases, immunocompromised patients may have fungal otitis external from Aspergillus or Candida
Microbiology
- Pseudomonas (most common)
- Staph/Strep
- Enterobacter
- Proteus mirabilis
- Fungus (may present after antibiotic treatment or in immunocompromised patient)
Risk Factors
- Swimming
- Excessive Q-tip (or other instrument) use
Clinical Features
- Rapid onset (generally within 48 hours) in the past 3 weeks, AND.[2]
- Symptoms
- Otalgia
- Fullness or itching of the ear
- Hearing loss
- Jaw pain
- Signs
- Tenderness of the pinaa and/or tragus
- Diffuse ear canal edema, erythema, and possibly debris
- Tympanic membrane may not be visualized due to EAC edema
- Otorrhea
- Local lymphadenitis
- Tympanic membrane erythema, or
- Cellulitis of the pinna and adjacent skin
Differential Diagnosis
Ear Diagnoses
External
- Auricular hematoma
- Auricular perichondritis
- Cholesteatoma
- Contact dermatitis
- Ear foreign body
- Herpes zoster oticus (Ramsay Hunt syndrome)
- Malignant otitis externa
- Otitis externa
- Otomycosis
- Tympanic membrane rupture
Internal
- Acute otitis media
- Chronic otitis media
- Mastoiditis
Inner/vestibular
Evaluation
- Normally clinical
- Routine labwork or EAC cultures typically not necessary
Management
Hygiene
- Clean the ear canal (Grade C)
- Cerumen wire loop or cotton swab usually works best
- 1:1 dilution of 3% hydrogen peroxide if tympanic membrane is visible and intact
- Acetic acid wash for debridement of dead skin
- Place a wick if the ear canal is fully obstructed
- Instruct patient that the wick should fall out spontaneously in 3 days as swelling decreases; a clinician may remove it otherwise
Analgesia
Prevention
- Keep ear canal dry
- Abstain from water sports for 7-10 days
- Counsel patient to avoid Q-tip or other foreign objects in the ear
Antibiotics
- Ofloxacin (Floxin otic): 5 drops in affected ear BID x 7 days[2]
- Safe with perforations
- Ciprofloxacin-hydrocortisone (Cipro HC): 3 drops in affected ear BID x 7 days
- Contains hydrocortisone to promote faster healing
- Not recommended for perforation since non-sterile preparation
- Ciprofloxacin-dexamthasone (Ciprodex): 4 drops in affected ear BID x 7 days
- Similar to Cipro HC but safe for perforations
- Often more expensive
- Cortisporin otic (neomycin/polymixin B/hydrocortisone): 4 drops in ear TID-QID x 7days
- Use suspension (NOT solution) if possibility of perforation
- Animal studies suggest possible toxicity from the neomycin although rigorous data is lacking[3]
- Instruct the patient to instill the medication into the ear while laying on their side and hold position for 3-5 minutes
- Typically a least 4 drops are needed to fill the entire ear canal
- Consider systemic antibiotics in specific cases:
- Immunosuppressed (HIV, poorly controlled diabetes, chemotherapy, chronic high dose corticosteroid use, immunosuppressive drugs, neutropenia) give systemic antibiotic (ciprofloxacin or ofloxacin) [4]
- If TMs are able to be visualized and suggest otitis media
- If there is a suspicion of malignant otitis externa
Disposition
- Discharge
- Follow up with PCP or ENT in 1-2 weeks for patients with moderate disease
See Also
External Links
References
- ↑ Beers SL, Abramo TJ. Otitis externa review. Pediatr Emerg Care. 2004 Apr;20(4):250-6. doi: 10.1097/01.pec.0000121246.99242.f5. PMID: 15057182.
- ↑ 2.0 2.1 Clinical Practice Guideline: Acute Otitis Externa Executive Summary. Otolaryngology -- Head and Neck Surgery 2014 150: 161 DOI: 10.1177/0194599813517659 PDF
- ↑ Wright, C. et al. Ototoxicity of neomycin and polymyxin B following middle ear application in the chinchilla and baboon. Am J Otol. 1987 Nov;8(6):495-9.
- ↑ Santos F, Selesnick SH, Gurnstein E. Diseases of the External Ear. In:Current Diagnosis and Treatment in Otolaryngology: Head and Neck Surgery, Lalwani AK (Ed), Lange Medical Books/McGraw-Hill, New York 2004.