Otitis externa medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Management of acute otitis externa (AOE) includes both cleaning the external auditory meatus and treating the infection. Topical therapy is recommended as initial therapy for diffuse, uncomplicated AOE. Systemic antimicrobials should be reserved for infections extending outside the external canal or patients with specific host factors. Analgesic agent should also be administered based on the severity of pain.
Antibiotic 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 canal or the presence of the following host factors that would indicate a need for systemic therapy:[1]
- 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
Acute Otitis Externa
Currently available topical agents comprise an antibiotic (an aminoglycoside, polymyxin B, a quinolone, or a combination of these agents), a steroid, and/or a low-pH antiseptic.
- Acetic acid 2.0% solution (Acetic acid otic)
- Acetic acid 2.0%, hydrocortisone 1.0% (Acetasol HC)
- Ciprofloxacin 0.2%, hydrocortisone 1.0% (Cipro HC)
- Ciprofloxacin 0.3%, dexamethasone 0.1% (Ciprodex)
- Neomycin, polymyxin B, hydrocortisone (Cortisporin Otic)
- Ofloxacin 0.3% (Floxin Otic)
Malignant (Necrotizing) Otitis Externa
Malignant otitis externa is the invasive infection of the external auditory meatus which predominantly affects elderly, diabetic, or immunocompromised patients. Diagnosis can be confirmed with increased erythrocyte sedimentation rate with an abnormalities in imaging studies. Treatment consists of surgical debridement and systemic antibiotics with activity against Pseudomonas aeruginosa and/or Staphylococcus aureus.
- Ciprofloxacin 400 mg IV q8h
- Piperacillin-Tazobactam 3.375g IV q4h AND
- Tobramycin 3–5 mg/kg/day IV q8h
- Imipenem 0.5 g IV q6h OR Meropenem 1 g IV q8h OR Cefepime 2 g IV q12h OR Ceftazidime 2 g IV q8h
Fungal Otitis Externa (Otomycosis)
Otomycosis is the fungal infection of external auditory canal leading to symptoms of pruritus and thickened otorrhea. It is commonly caused by Aspergillus or Candida species and observed in tropical countries, after long-term topical antibiotic therapy, and in patients with diabetes, HIV infection, or an immunocompromised state.
- Fluconazole 200 mg po x 1 dose, then 100 mg po x 3–5 days
Chronic Otitis Externa
- Neomycin, polymyxin B, hydrocortisone 4 drops tid or qid AND
- Selenium sulfide shampoo
Pain Management
Analgesic agent 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 pain 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)[2]
| 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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
References
- ↑ Rosenfeld, Richard M.; Schwartz, Seth R.; Cannon, C. Ron; Roland, Peter S.; Simon, Geoffrey R.; Kumar, Kaparaboyna Ashok; Huang, William W.; Haskell, Helen W.; Robertson, Peter J. (2014-02). "Clinical practice guideline: acute otitis externa". Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 150 (1 Suppl): –1-S24. doi:10.1177/0194599813517083. ISSN 1097-6817. PMID 24491310. Check date values in:
|date=(help) - ↑ Rosenfeld, Richard M.; Schwartz, Seth R.; Cannon, C. Ron; Roland, Peter S.; Simon, Geoffrey R.; Kumar, Kaparaboyna Ashok; Huang, William W.; Haskell, Helen W.; Robertson, Peter J. (2014-02). "Clinical practice guideline: acute otitis externa". Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 150 (1 Suppl): –1-S24. doi:10.1177/0194599813517083. ISSN 1097-6817. PMID 24491310. Check date values in:
|date=(help)