Otitis externa medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Template:Chi; Maliha Shakil, M.D. [2]; Suveenkrishna Pothuru, M.B,B.S. [3]; Luke Rusowicz-Orazem, B.S.; Tarek Nafee, M.D. [4]

Overview

The mainstay of therapy for acute otitis externa (AOE) includes cleaning of the external auditory meatus and treating the infection. Topical therapy is recommended as the initial therapy for diffuse uncomplicated acute otitis externa. Systemic antimicrobials should be reserved for infections extending outside the external ear canal or patients with specific risk factors. Analgesics such as acetaminophen or nonsteroidal anti-inflammatory drugs are administered either alone or in combination with an opioid.

Medical Therapy

Topical therapy is recommended as initial therapy for diffuse uncomplicated AOE. A non-ototoxic topical preparation should be used when the patient has a known or suspected perforation of the tympanic membrane. Systemic antimicrobials may be administered if there is extension outside the external ear canal or in the presence of the following risk factors that would indicate a need for systemic therapy:

• Diabetes
• HIV infection or AIDS
• Other immunocompromised states, such as patients with malignancies receiving chemotherapy
• History of radiotherapy
• Presence of tympanostomy tube or perforated tympanic membrane

Otitis externa

• 1. Otitis externa, acute

• 1.1 Causative pathogens

• Pseudomonas aeruginosa
• Candida spp.
• Enterobacteriaceae
• Proteus spp.
• Staphylococcus aureus

• 1.2 Empiric antimicrobial therapy

• Preferred regimen (1): Acetic acid 2.0% TOP tid for 7-10 days
• Preferred regimen (2): Acetic acid 2.0%, Hydrocortisone 1.0% TOP tid for 7-10 days
• Preferred regimen (3): Ciprofloxacin 0.2%, Hydrocortisone 1.0% TOP tid for 7-10 days
• Preferred regimen (4): Ciprofloxacin 0.3%, Dexamethasone 0.1% TOP tid for 7-10 days
• Preferred regimen (5): Neomycin, Polymyxin B, Hydrocortisone TOP tid for 7-10 days
• Preferred regimen (6): Ofloxacin 0.3% TOP tid for 7-10 days

• 1.3 Pathogen-directed therapy

• 1.3.1 Fungal otitis externa

• Preferred regimen: Fluconazole 200 mg PO once THEN Fluconazole 100 mg PO q24h for 3–5 days

• 1.3.2 Malignant otitis media, Pseudomonas aeruginosa

• Preferred regimen: Imipenem 0.5 g IV q6h OR Meropenem 1 g IV q8h OR Ciprofloxacin 400 mg IV q8h OR Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q12h OR (Piperacillin-Tazobactam 4-6g IV q4h AND Tobramycin 3–5 mg/kg/day IV q8h)
• Note: Oral Ciprofloxacin may be used by only in patients with very early disease

• 2. Otitis externa, chronic

• 2.1 Empiric antimicrobial therapy

• Preferred regimen: Neomycin, Polymyxin B, Hydrocortisone TOP q6-8h AND Selenium Sulfide Shampoo
• Note: Selenium sulfide shampoo is recommended as the disease is usually secondary to seborrhea.

Pain Management

Analgesia should be administered based on the severity of pain. Mild to moderate pain is usually managed with acetaminophen or nonsteroidal anti-inflammatory drugs given alone or in combination with an opioid. Fentanyl, morphine, and hydromorphone are indicated for procedure-related and moderate to severe pain.

Algorithm for the Approach to Acute Otitis Externa

Abbreviations: AOE, acute otitis externa; TM, tympanic membrane. (Adapted from Clinical Practice Guideline: Acute Otitis Externa)

Diffuse AOE

Analgesic based on severity

Extension beyond ear canal or ⊕ factors requiring systemic Rx?

YES

NO

Abx against P. aeruginosa and S. aureus

Perforated TM?

YES

NO

Non-otoxic topical agent

Topical agent

Obstructed ear canal?

YES

NO

Aural toilet or wick placement

Educate pt on how to use ear drops

Clinically improve in 3 days?

YES

NO

Complete Rx course

Illness other than AOE?

YES

NO

Treat accordingly

Assess Rx adherence/delivery