17/2/22, 17:10 Otitis Externa - ClinicalKey

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CLINICAL OVERVIEW  

Otitis Externa 
Elsevier Point of Care  (ver detalles)

Actualizado October 1, 2021. Copyright Elsevier BV. All rights reserved.

Synopsis

Key Points Urgent Action

Acute otitis externa accounts for over 95% of cases of otitis Early diagnosis of
externa and is characterized by development of symptoms malignant otitis externa
within 48 hours of presentation; most often caused by and the rapid initiation of
bacterial pathogens (eg, Staphylococcus, Pseudomonas) parenteral antibiotics is
essential to reduce
Chronic otitis externa has many causes and is much less
associated morbidity and
frequently bacterial in etiology
mortality 4
Acute and chronic otitis externa present similarly with
otalgia, otorrhea, and abnormal findings on examination of
the external ear and auditory canal (eg, erythematous canal, tenderness to manipulation of
tragus and pinna)

Common predisposing factors to the development of otitis externa are excessive moisture in
the external auditory canal, obstruction of canal, disrupted epithelial integrity, and disrupted
protective cerumen layer in the canal

Diagnosis of otitis externa is based on clinical presentation; laboratory and imaging studies do
not aid in the diagnosis of otitis externa except in very limited clinical situations in which
culture can aid in determining exact etiology

Treatment for most patients with acute otitis externa includes pain management, topical
antimicrobials, appropriate aural toilet and removal of external auditory canal debris, ear wick
(when indicated), and precipitant avoidance
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Systemic antibiotics are rarely necessary; use of oral antibiotics is limited to patients at high
risk of complications (eg, patients with immunocompromise, diabetes, or with history of
radiation to the head), patients in whom there is extension of cellulitis outside of the external
auditory canal, patients in whom topical medication delivery is not possible (eg, canal stenosis),
topical antibiotic treatment failure, and patients with concurrent otitis media

Monitor patients for symptom resolution; reevaluate patients whose acute symptoms do not
improve with treatment in 2 to 3 days and patients without complete symptom resolution in 2
weeks 1

Preventive measures are important to avoid recurrence (eg, drying external auditory canal after
exposure to moisture or swimming, avoiding self-inflicted trauma to canal)

Potential complications of acute otitis externa include malignant otitis externa, extension of
infection beyond external auditory canal to surrounding tissues, and canal stenosis

Prognosis is excellent with adequate treatment, and full recovery is expected within 1 week. 2
Patients often experience marked improvement after 1 day 3

Pitfalls
Fever and malaise do not occur in patients with otitis externa limited to the external auditory
canal; carefully assess for alternate diagnosis (eg, malignant otitis externa, otitis media with
otorrhea) in patients presenting with systemic signs and symptoms 5

Avoid use of oral antibiotic therapy in patients with otitis externa unless otherwise indicated;
inappropriate use of oral antibiotics for uncomplicated otitis externa in otherwise healthy
individuals leads to persistent infection, recurrence of infection, and antibiotic resistance 3

Avoid topical ototoxic antiseptic and antibiotic regimens in patients with compromised
tympanic membrane integrity (eg, perforation, tympanostomy tubes); confirm integrity of
intact tympanic membrane with history and direct visualization before treating external otitis
with topical ototoxic medications 3

Terminology

Clinical Clarification
Otitis externa is inflammation of the external auditory canal with or without infection 5

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Classification
Classification based on chronicity

Acute otitis externa (also known as swimmers ear or tropical ear) 1

Characterized by marked inflammation of the external auditory canal occurring within 48

hours of presentation 1

Almost always is cellulitis of the external auditory canal skin and subdermis; infection
may involve the pinna, tragus, and/or tympanic membrane 1

Over 95% of cases of otitis externa are acute 5

Chronic otitis externa

Various definitions exist, including:

A single episode of otitis externa lasting longer than 4 weeks, or 3

4 or more episodes of otitis externa in 1 year, or 3

Inflammation lasting 3 months or longer 5 6

Causes are numerous; noninfectious causes are more common 5

Classification based on extent of inflammation

Diffuse otitis externa

Characterized by extensive, diffuse inflammation of the external ear canal

Localized otitis externa 1

Characterized by localized, focal inflammation of the external ear canal (eg, furuncle)

Classification based on severity 7

Mild

Characterized by mild signs and symptoms

Moderate

Canal lumen is partially occluded

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Characterized by increasing pruritus and pain

Severe

Canal lumen is obstructed

Associated with intense pain and extracanal signs (eg, auricular cellulitis, regional
lymphadenopathy)

Diagnosis

Clinical Presentation

History
Acute otitis externa

Rapid onset of symptoms within 48 hours 1

Acute otitis externa (eg, bacterial infection) can complicate

chronic otitis externa 5
Otoscopic view of otitis externa. -
Up to 90% of cases are unilateral 8 Edema of the ear canal obscures the
tympanic membrane.
Chronic otitis externa

Recurrent or persistent symptoms lasting 1 month to more than 3 months 5 3

Often characterized by a waxing and waning course with intermittent disease exacerbations
over the course of years 5

Up to 50% of cases are bilateral 5

Symptoms of ear canal inflammation

Discomfort in the external auditory canal is the most characteristic symptom and is present
in most patients 9

Otalgia

Pain is often intense and may worsen with jaw motion 10

10
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Characteristically described as disproportionate to examination findings 10

Occurs in up to 70% of patients with acute otitis externa 11

Pruritus

Often a precursor to otalgia

Occurs in up to 60% of patients with acute otitis externa 11

Often more pronounced in patients whose cause of disease is otomycosis, allergy, or

chronic and dermatologic in nature

Sensation of fullness

Occurs in up to 22% of patients with acute otitis externa 11

Decreased auditory acuity

May be secondary to external auditory canal obstruction (eg, swelling, debris) 11

Referred jaw pain may occur 1

Physical examination
Tenderness of the tragus when pushed and the pinna when gentle traction is applied are
hallmark signs of ear canal inflammation 1

Exquisite pain elicited with manipulation of the tragus or pinna is characteristic, especially
in patients with acute otitis externa

Other evidence of ear canal inflammation on direct visualization:

Diffuse external auditory canal edema and erythema occur in the majority of patients

Occasionally, inflammatory changes extend to the pinna and adjacent skin 1

Other variable signs

Otorrhea 1

Usually scant early in illness

Often evolves to thick and clumpy or purulent discharge mixed with soft white
cerumen later in illness
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Regional periauricular lymphadenopathy and edema can develop late in patients with
severe disease 1

Tympanic membrane erythema 1 with normal mobility can develop if inflammation

extends to the external tympanic membrane, causing myringitis

Isolated pustular lesion in the external auditory canal can be observed in patients with
localized otitis externa 1

In severe disease, external auditory canal can become nearly obstructed by edema, otorrhea,
and additional debris 5

Other external auditory canal findings in patients with chronic otitis externa vary depending
on cause 5

Patients with contact dermatitis (irritant or allergic) may have a maculopapular rash and
excoriations

When allergic in nature, characteristic rash assumes a patterned distribution with

concentration in the conchal bowl and possible linear erythematous streaks (representing
drip marks) extending from ear canal

Patients with chronic dermatologic conditions show eczematous changes with

lichenification and epithelial hyperkeratosis

Patients with seborrhea show a lack of cerumen, with dry and flaky or greasy, yellowish skin
in canal 1

Characteristics of fungal infections 1 5

Fluffy, cottonlike white debris with sprouting hyphae in canal is typical for Candida species

Moist white plug dotted with black debris (wet newspaper appearance) is typical for
Aspergillus niger infection

Thick otorrhea of various colors (eg, black, gray, bluish green, yellow, white)

Infection often localizes initially in the medial aspect of the canal in the inferior recess
(immediately adjacent to the lower aspect of the tympanic membrane)

Causes and Risk Factors

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Causes
Acute otitis externa

Disruption of external auditory canal epithelium (eg, from trauma to canal or breakdown of
epithelium) or natural host defenses (eg, disruption of protective cerumen layer, obstruction
of canal drainage, disruption of the normal acidic environment) predisposes to infection 1

Elements that predispose patients to infection are often multifactorial 1

98% of pathogens responsible for disease in North America are bacterial; infection is often
polymicrobial 1

Pseudomonas aeruginosa (20%-60% of cases) 1

Staphylococcus aureus (10%-70% of cases), including MRSA 12 1

Other non-Pseudomonas gram-negative organisms (2%-3% of cases) 1

Fungal pathogens are responsible for less than 2% of acute otitis externa cases; however,
topical antibiotics used to treat acute otitis externa can lead to secondary fungal infection 3

Aspergillus and Candida are the most commonly encountered fungal pathogens 4

Chronic otitis externa has many causes, including: 5

Complication of inadequately treated bacterial acute otitis externa or fungal infection (eg,
otomycosis)

Complication of recalcitrant bacterial infection in immunocompromised patients

Recurrence or persistence of bacterial infection secondary to lack of preventive measures (eg,

avoidance of moisture or trauma)

Underlying condition, such as:

Allergic contact dermatitis involving the external auditory canal 1

Causes include drugs (eg, neomycin, other otic preparations), chemicals (eg, detergents,
soaps, shampoos, cosmetics, hair spray or hair products), metals (eg, nickel, silver),
leather, rubber, and plastics (eg, hearing aid molds)

Irritant contact dermatitis (typically caused by products such as shampoos, detergents,

and hair products)

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Dermatoses involving the external auditory canal (eg, atopic dermatitis/eczema,

seborrheic dermatitis, contact dermatitis)

Autoimmune disease (eg, Wegener granulomatosis, sarcoidosis) 5

Malignancy

Risk factors and/or associations

Age
Peak incidence in children aged 7 to 12 years and adults aged 65 to 74 years 3

Rare in children younger than 2 years 1

Genetics
Patients with type A blood group are more susceptible to otitis externa 1

Other risk factors/associations

Seasonality

More frequent in summer months in North America 13

More frequent in warm, humid climates 5

Geographic influences

In the United States, disease is most common in the south and least common in the west 1

Predisposing factors that increase risk of acute otitis externa include:

Excessive moisture in the external auditory canal (eg, frequent swimming, prolonged
exposure to water or sweat) 3

Acute otitis externa is 5 times more common in regular swimmers 5

Obstruction of external auditory canal 3

Causes include foreign body, cerumen impaction, hearing aids, earplugs, ear phones,
canal stenosis, dermoid cyst, or sebaceous cyst

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Certain anatomic factors increase risk of obstruction, such as excessively narrow canal,
tortuous canal, excessive hair in canal, and abnormal cerumen production

Disrupted epithelial barrier or loss of protective cerumen layer in the canal 3

Self-induced trauma (eg, instrumentation, cleaning with cotton-tipped swabs)

Dermatologic conditions (eg, eczema, seborrhea, psoriasis) 4

Purulent drainage from acute otitis media through tympanostomy tubes or perforated
tympanic membrane can macerate epithelium

Contact irritation from products (eg, soaps, detergents), allergic irritation, or foreign
objects (eg, hearing aids, ear plugs)

Excessive cleaning 5

Chronic otitis externa predisposes individuals to acute otitis externa 5

Prior radiation therapy to head and neck

Otomycosis is more common in tropical countries, after patient has taken long-term topical
antibiotic therapy; also more common in people with diabetes and those who are
immunocompromised 1

More severe and persistent acute otitis externa occurs in patients with immunocompromise
(eg, HIV, diabetes) 5

Diagnostic Procedures

  Primary diagnostic tools

Diagnosis of acute otitis externa is based on clinical presentation; laboratory and imaging
studies do not aid in the diagnosis of acute otitis externa 1

Rapid onset (within 48 hours occurring in the past 3 weeks) and signs and symptoms of
ear canal inflammation are diagnostic of acute otitis externa 1

Select patients presenting with otitis externa may require bacterial and/or fungal cultures
of otorrhea to specify cause

Indications for bacterial and fungal cultures of external auditory canal discharge include
patients with:

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Resistant or recurrent otitis externa with immunocompromise or a history of

frequent topical antibiotic use 5

Chronic otitis externa 5

Suspected significant complications (eg, necrotizing otitis externa) 5

Imaging with CT, MRI, or nuclear medicine studies may be required if complications
such as malignant or necrotizing otitis externa is suspected 14 15

  Laboratory

Differential Diagnosis

Malignant external otitis. - Patients have a history of nonresolving otitis externa of many weeks’ duration. Most patients
are diabetic. Pseudomonas organisms invade underlying soft tissues. There is severe ear pain, a purulent exudate, and
granulation tissue. Nuclear scanning studies and CT scans may reveal osteomyelitis of the skull base.

Malignant otitis externa. - Severe infection of the ear has occurred after months of chronic inflammation of the pinna.

Most common
Referred pain

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Common cause of otalgia; causes include: 1

Temporomandibular joint syndrome (eg, from gum chewing, bruxism, or recent dental
procedure)

Upper aerodigestive tract malignancy

Dental pathologies (eg, caries, impacted molars)

Tonsillitis

Peritonsillar abscesses

Retropharyngeal abscesses

Carotidynia

Styloid process elongation

Angina

Intrathoracic aneurysms

Glossopharyngeal neuralgia

Geniculate neuralgia

As opposed to patients with otitis externa, patients with referred pain have normal
external auditory canal examination results

Differentiate with history and physical examination and additional focused diagnostic
workup based on clinical suspicion of specific underlying cause to further delineate
alternate underlying pathology as indicated

Necrotizing otitis externa (malignant otitis externa)

Rare, aggressive, severe infection of the external auditory canal, surrounding support
structures, and bone (eg, mastoid, temporal bone); over 90% of cases are caused by
Pseudomonas 3

Many experts regard necrotizing otitis externa as a complication of untreated otitis

externa 5; necrotizing otitis externa may represent a unique, rapidly invasive infectious
process and separate pathophysiologic entity from acute otitis externa

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Almost exclusively occurs in adult patients (primarily in elderly people) and patients with
immunocompromise (eg, diabetes, HIV); over 90% of patients who develop necrotizing otitis
externa have diabetes 5

Early in the necrotizing otitis externa disease process, patients can present with similar,
but more intense, symptoms (eg, otalgia, otorrhea) as patients with acute otitis externa

Eventually, patients will develop high fever, malaise, severe pain out of proportion to
examination findings, and granulation tissue along the floor of the external auditory canal;
may develop cranial nerve palsies, vertigo, and meningeal signs

Fever and malaise do not occur with otitis externa; differentiate diseases by clinical
presentation, disease course, and imaging

Confirm necrotizing otitis externa by imaging; CT identifies extension of infection

outside of the external auditory canal (eg, bony erosion, soft tissue involvement), whereas
MRI better characterizes soft tissue abnormalities and identifies retrocondylar fat
infiltration, a finding present in 93% of patients with necrotizing otitis externa 3

Otitis media 16 (Related: Acute Otitis Media)

Otitis media with purulent otorrhea can occur secondary to a perforation in the tympanic
membrane or in patients with patent tympanostomy tubes; draining otitis media can result
in secondary otitis externa

Acute otitis media presents similarly to otitis externa with sudden-onset otalgia associated
with an erythematous tympanic membrane; otorrhea occurs when a defect is present in the
tympanic membrane and otalgia typically diminishes following perforation

Patients with acute otitis media typically have other associated symptoms (eg, fever,
concurrent upper respiratory infection) and have evidence of middle ear effusion on
examination (eg, bulging tympanic membrane, decreased mobility with insufflation)

In contrast to patients with otitis externa, patients with otitis media lack tenderness with
manipulation of the tragus and pinna

Otitis media is more likely if patient is younger than 2 years 11

Differentiate by clinical presentation; tympanometry can assist in confirming otitis media

if the diagnosis remains in question because most patients with otitis media exhibit an
abnormal tympanometry tracing (eg, flat type-B tracings) 1 and patients with a normal
tympanic membrane show a normal, peaked-curve, type A tympanometry tracing 5 11

Chronic suppurative otitis media (Related: Eczema and Atopic Dermatitis)

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Presents with recurrent or persistent otorrhea through perforated tympanic membrane

lasting longer than 2 to 6 weeks; patients with chronic suppurative otitis media can result in
secondary otitis externa

As opposed to patients with otitis externa, otorrhea associated with chronic suppurative
otitis media is longstanding in nature and pain is not pronounced

Patients with chronic suppurative otitis media without otitis externa lack significant
tenderness to tragal manipulation, and an observable defect in tympanic membrane is often
apparent

Differentiate based on history and physical examination findings

Dermatoses involving the external auditory canal 1

Various dermatologic conditions (eg, atopic dermatitis/eczema, seborrheic dermatitis,

contact dermatitis) involving the ear canal can mimic otitis externa and present with ear
discomfort, discharge from the ear canal, external auditory canal erythema, and edema 1
(Related: Eczema and Atopic Dermatitis)

Dermatologic conditions that affect the integrity of the skin barrier in the auditory canal
can lead to secondary otitis externa

Pruritus is often more intense in patients with underlying dermatologic conditions; they
often have evidence of additional underlying disease elsewhere on body discovered with
thorough cutaneous examination 11

Discharge from the external auditory meatus, when encountered, is often more scaling or
flaky and less purulent in nature 11

Differentiate diseases based on clinical presentation and disease course

Allergic or contact dermatitis involving the external auditory canal

Many substances can cause a local reaction that mimics otitis externa with ear discomfort,
external auditory canal discharge, canal erythema and edema (eg, neomycin, benzocaine,
propylene glycol otic preparation preservative, shampoos, detergents, hair sprays, hearing
aid molds) 5

The aminoglycoside neomycin carries a high risk of allergic sensitization; up to 15% of

otherwise healthy individuals develop contact sensitivity to neomycin, and up to 30% of
individuals with chronic or eczematous otitis externa develop sensitivity 5

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Contact and allergic reactions are often more pruritic than painful; allergic reactions for
otic drops present with characteristic examination findings that include a patterned rash
with accentuation in the conchal bowl and erythematous streak extending from the external
auditory meatus (ie, drip pattern) 1

Differentiate diseases based on clinical presentation and clinical course; skin patch testing
can definitively identify the cause of allergic contact dermatitis if the diagnosis remains in
question 5

Foreign body in the external auditory canal

A subtle foreign body in the external auditory canal can mimic otitis externa; a retained
foreign body can cause otitis externa

Can present similarly to otitis externa with ear discomfort and otorrhea; otorrhea tends to
be purulent and foul smelling, often improving with antibiotic treatment and then
recurring after antibiotics are stopped

Foreign body is often visible in external auditory canal on examination

Differentiate by history and physical examination

Cholesteatoma

Abnormal nonmalignant tumor that develops as a result of migration of keratinized

hyperproliferative squamous epithelium into the middle ear space. Acquired cholesteatoma
is a complication of repeated bouts of otitis media or chronic otitis media; congenital cases
are rare

Presents with malodorous otorrhea, ear discomfort, hearing loss, mass in the middle ear
space, and sometimes otalgia; on examination, cholesteatoma appears as a whitish rounded
mass visible deep behind the tympanic membrane, usually anteriorly or anterosuperiorly 17

Many complications from excessive growth can result if not treated (eg, bony erosion,
permanent hearing loss, perilymphatic fistula, facial nerve paralysis, intracranial infectious
complications)

Differentiate from otitis externa by clinical presentation and clinical course; differentiate
disease by imaging if the diagnosis remains in question (CT is preferred over MRI) 18

Herpes zoster oticus (Ramsay Hunt syndrome) 1

Caused by reactivation of varicella-zoster virus in the cutaneous distribution of the auricle

and external auditory meatus; can result in facial and vestibulocochlear neuropathy

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Presents similarly to otitis externa with severe otalgia; additional findings include a
vesicular rash in the external ear canal, loss of taste on the anterior two-thirds of the tongue,
and decreased lacrimation on the involved side 1

Patients may present with facial paralysis and vertigo 19

Differentiate diseases based on clinical presentation; 20if diagnosis remains in question,

confirm with a positive result on Tzanck test and polymerase chain reaction to detect
varicella-zoster virus DNA on skin lesion specimen

Malignancy

Rarely, squamous cell carcinoma presents similarly to otitis externa with ear discomfort
and otorrhea

A mass in the external auditory canal evident on examination distinguishes malignancy

from otitis externa

Definitive diagnosis is confirmed by biopsy of lesion

Treatment

Goals
Control symptoms 1

Eradicate infection 1

Promote antibiotic stewardship

Avoid precipitating factors

Disposition

Admission criteria
Not indicated for patients with uncomplicated otitis externa

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May be required for patients worsening on maximum outpatient therapy, certain patients with
severe immunocompromise, and patients with severe complications (eg, malignant otitis
externa) 21

Recommendations for specialist referral

Patients with persistent foreign body despite attempts at removal or debris obstructing canals
despite attempts at relieving obstruction require further evaluation and management by an
otolaryngologist 22

If condition does not respond or worsens on standard therapy, refer patient to an

otolaryngologist for further diagnostic and treatment recommendations; consider consultation
with subspecialist for patients who require oral antibiotics for otitis externa 11

Refer patients with suspected malignant otitis externa or persistent chronic otitis externa
despite management to an otolaryngologist for further diagnostic and treatment
recommendations 5

Treatment Options
Pain management is paramount for patients with acute otitis externa 1

Most patients will experience diminished pain with prompt administration of topical
antibiotic with or without topical corticosteroid

Oral administration of analgesics is the preferred route of administration 1

Treat mild to moderate pain with acetaminophen and NSAIDs at fixed intervals 1 3

Treat severe pain with opiate narcotics 23 (eg, oxycodone, hydrocodone) sparingly; provide
supply for pain control for 2 to 3 days maximum 1 3

Maintain caution with use of opiate narcotics owing to risk of masking severe
complications (eg, malignant otitis externa) or inadequate treatment

Patients occasionally require acute analgesia and occasionally procedure-related sedation with
opioids (eg, fentanyl citrate, morphine sulfate) 1

Use topical anesthetic preparations with caution; proof of efficacy is lacking, and some experts
warn that topical preparations may mask the progression of worsening severe disease or the
development of complications (eg, malignant otitis externa) 1 3 5

Topical otic anesthetic drops are not FDA approved for treatment of otitis externa 1
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Mandatory reassessment in 48 hours is recommended if topical otic anesthetic drops are

prescribed for temporary pain relief

Topical otic anesthetic drops are contraindicated in patients with a nonintact tympanic
membrane (ie, tympanostomy tubes or perforation)

Addition of topical steroid preparation combined with topical antibiotic drops may hasten
pain relief in patients with acute otitis externa by about 1 day compared with antibiotic drops
alone 3 5

Topical antibiotic therapy is first line standard of care treatment for most patients with acute
otitis externa 3

Topical antibiotic treatment for 7 days is highly effective; antiseptic/acidifying agents are
effective alternatives to topical antibiotic drops for patients with mild acute otitis externa with
an intact tympanic membrane 2 3

Topical therapy delivers a very high concentration of antimicrobial directly to infected

tissue; 100 to 1000 times higher local antibiotic concentrations are achieved with topical
compared with systemic antimicrobials 1

Avoid topical ototoxic antiseptic and antibiotic regimens in patients with compromised
tympanic membrane integrity (eg, perforation, tympanostomy tubes) or when tympanic
membrane cannot be visualized 3 23

Acetic acid 5

Most often used for mild disease in clinical practice

Preparations lose efficacy if treatment is required beyond 1 week 2

Symptoms may persist up to 2 days longer in patients treated with acetic acid 2

Preferred topical antibiotic agent is unclear 24

Base initial choice of topical treatment on patient allergies, risk of ototoxicity, local
antibiotic resistance patterns, and ease of dosing 2

Addition of topical steroid to treatment regimen may hasten resolution of canal edema and
otorrhea 2 5 25

Effective treatment for acute otitis externa is characterized by marked improvement in pain
and other symptoms over the course of 2 to 3 days 3

Adequate topical medication delivery is important for patients with acute otitis externa 1

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Perform aural toilet and/or place ear wick when indicated to facilitate adequate delivery of
topical medication to distal external auditory canal

Avoid topical ototoxic antiseptic and antibiotic preparations in patients with compromised
tympanic membrane integrity (ie, perforation or tympanostomy tubes) and when tympanic
membrane cannot be visualized 3 23

Topical ototoxic medications that reach the inner ear can lead to hearing loss and vertigo 5

Ototoxic preparations include any containing acidifying agents, aminoglycosides (eg,

neomycin, gentamicin, tobramycin), or alcohol and antiseptics 23

Consider children with the following to have a defect in the tympanic membrane:

Tympanostomy tube placement within the past year 3

Those who can taste topical otic medications after placement of the medication in the
external auditory canal

Those who can expel air from the ear

Systemic antibiotics are rarely necessary 5 26

Use oral antibiotics with efficacy against Staphylococcus and Pseudomonas when indicated, in
consultation with specialist (eg, otolaryngologist, infectious disease specialist) 3 10

Consider need for MRSA coverage 12

Indications for systemic antibiotics in select patient populations include: 1 3

High risk for complications (eg, those with immunocompromise, diabetes, history of
radiation to the head, 5 high risk for development of malignant otitis externa)

Evidence of significant extension of cellulitis outside of the external auditory canal or

concern for worsening severe disease 5

Severe disease 23 (eg, canal stenosis or severe canal edema limiting penetration of topical
antibiotics) 5

Persistent bacterial otitis externa failing appropriate topical antibiotic therapy and
management 11

Avoid cephalosporins owing to increased risk of recurrence and increased disease persistence;
avoid penicillins and macrolides owing to increased disease persistence 1

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Oral antibiotic choices for pediatric patients are limited; consider patient care in consultation
with otolaryngologist or infectious disease specialist when oral antibiotics are required

Treat patients with otitis externa and concurrent draining otitis media with appropriate oral
antibiotics aimed at treating the otitis media combined with non-ototoxic topical antibiotics
aimed at treating otitis externa 1 11

Patients with otomycosis 1

Manage with surgical debridement plus topical antifungal therapy (eg, clotrimazole 1% cream)
5
in consultation with otolaryngologist

Gentian violet applied in office is an alternate effective treatment; acidifying agents are
additionally beneficial 5

Treat recalcitrant or severe infections with oral itraconazole 5

Topical antibiotic treatment is contraindicated; antibiotics promote further fungal overgrowth

1

Patients with chronic otitis externa 5

Recommend aural toilet (if indicated) and preventive precautions for acute otitis externa

Aim treatment at addressing and controlling underlying cause

Avoid contact with irritants in patients with contact dermatitis

Topical medium (eg, triamcinolone 0.1% cream) or high-potency steroid agent (eg,
desoximetasone 0.05% cream) is usually effective for patients with contact dermatitis or
chronic dermatologic condition 5

Ophthalmic or nasal steroid preparations can also be applied to the external ear canal 27

Be aware that some cases of chronic otitis externa may represent contact allergy to topical
medications used to treat otitis externa, especially neomycin: a small percentage of patients
have allergies to topical steroids 28

Occasionally, a short course of oral steroids may be required; topical tacrolimus is effective
second line treatment when infection has been excluded 5

Drug therapy
FDA-approved topical otic preparations used to treat acute otitis externa 1

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Acetic acid drops

Acetic Acid Otic drops, solution; Adults, Adolescents, and Children >= 3 years: Instill 4—6
drops into the external auditory canal of the affected ear(s). Repeat q2—3hr.

Acetic acid/hydrocortisone drops

Hydrocortisone, Acetic Acid Otic drops, solution; Adults, Geriatric, Adolescents, and
Children >= 3 years: Insert cotton wick into external ear canal and saturate with solution;
keep moist by adding 3—5 drops of solution q4—6h. Replace wick at least once q24h. If
preferred, may remove wick after 24 h; however, continue dosage of 3—5 drops into the
ear(s) 3—4x/day for as long as indicated. Use lower end of dosage for children.

Ciprofloxacin drops 29

Ciprofloxacin Hydrochloride Otic drops, solution; Children and Adolescents: 0.5 mg (0.25
mL) in affected ear(s) every 12 hours for 7 days.

Ciprofloxacin/hydrocortisone drops

Ciprofloxacin Hydrochloride, Hydrocortisone Otic drops, suspension; Adults,

Adolescents, and Children 1 year and older: 3 drops instilled into the affected ear(s) twice
daily for 7 days.

Ciprofloxacin/dexamethasone otic suspension

Ciprofloxacin Hydrochloride, Dexamethasone Otic drops, suspension; Adults,

Adolescents, Children and Infants >= 6 months: 4 drops into affected ear(s) bid x 7 days.

Neomycin/polymyxin B/hydrocortisone drops

Neomycin, Polymyxin B, Hydrocortisone Otic drops, solution; Infants, Children, and

Adolescents: 3 drops in affected ear(s) 3 to 4 times per day. Treatment should not be
continued longer than 10 days.

Neomycin, Polymyxin B, Hydrocortisone Otic drops, solution; Adults: 4 drops in affected

ear(s) 3 to 4 times per day. Treatment should not be continued longer than 10 days.

Ofloxacin drops 11

Ofloxacin Otic drops, solution; Infants and Children 6 months to 13 years: 5 drops (0.25
mL or 0.75 mg) instilled into the affected ear(s) once daily for 7 days.

Ofloxacin Otic drops, solution; Adults: 10 drops (0.5 mL or 1.5 mg) instilled into the
affected ear(s) once daily for 7 days.
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Topical antifungal agent for patients with otomycosis

Clotrimazole otic solution 30

Clotrimazole Topical solution; Children and Adolescents 2 to 17 years: Apply to affected

skin and surrounding areas twice daily.

Clotrimazole Topical solution; Adults: Apply to affected skin and surrounding areas twice
daily.

Topical steroid preparations for patients with chronic otitis externa and contact dermatitis or
chronic dermatologic conditions 5

Triamcinolone Acetonide Topical 0.1% cream; Adults, Adolescents, and Children: Apply
sparingly to the external aural canal meatus twice daily.

Desoximetasone Topical 0.05% cream; Adults, Adolescents, and Children age 10 years and
older: Apply sparingly to the external aural canal meatus twice daily.

Oral antibiotics

Rarely needed except for select patient populations, including: 5

Immunocompromised people

Patients with diabetes

Patients with evidence of cellulitis extension outside of the external auditory canal

Ciprofloxacin

Ciprofloxacin Hydrochloride Oral tablet; Adults: 500 to 750 mg PO every 12 hours for 7 to
14 days.

For otitis externa that requires treatment with oral antibiotics, consult with a subspecialist
(eg, otolaryngologist, infectious disease consultant)

Nondrug and supportive care

Ensure appropriate and adequate topical medication delivery 1

Before patient discharge, ensure patency of external auditory canal for adequate penetration of
topical medications by performing aural toilet (ie, ear lavage) and/or placement of ear wick
when indicated

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Aural toilet 5

Clear debris with body-temperature fluid irrigation (eg, water, saline, hydrogen peroxide),
1
gentle suctioning, and/or dry mopping with cotton-tipped applicator

Avoid irrigation in the following cases

Patients with nonintact tympanic membrane

Patients with poorly controlled diabetes or immunocompromise, owing to

association of malignant otitis externa following irrigation in these patient
populations

Remove impacted cerumen and any foreign bodies

Ear wick 1 10

Place an expandable cellulose (preferred) or ribbon gauze wick 1 gently in the ear canal to
ensure distal penetration of antimicrobial agent; once placed, moisten with 6 drops of
antibiotic preparation 31

Indicated for patients with significant edema of the external auditory canal (ie, when the
majority of tympanic membrane cannot be visualized) and when external auditory canal
obstruction is anticipated to limit delivery of antimicrobial agent to the distal canal 1

Ear wick will usually expel itself in the first few days as inflammation improves;
alternatively, patient can remove wick after symptoms improve or clinician can remove at
follow-up 5

Demonstrate effective installation of first dose of ear drops in office when possible before
patient discharge 5

A common cause of initial treatment failure is improper installation of topical antibiotic

drops; up to 40% of patients self-administer drops incorrectly 5

Instruct patients on effective installation of topical medication drops with the following
sequence:

Patient lies down with affected ear upward

Optimally, someone other than the patient administers drops until the affected external
auditory canal is filled

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Gently vibrate or manipulate pinna and outer ear to ensure complete filling and eliminate
trapped air

Leave medication in place for at least 3 to 5 minutes

Recommend precipitant avoidance 1 3

Reduce moisture exposure to the ear

Avoid water sports and swimming with head submersion under water; competitive
swimmers should avoid swimming for at least 2 to 3 days 5

Use earplugs or cotton with petroleum jelly when bathing

Use a hair dryer on the lowest setting to reduce any remaining moisture in the external
auditory canal after potential water exposure

Avoid hearing aids, ear phones, and ear plugs (when not protecting from water exposure while
bathing) until pain and discharge have subsided 5

Recommend preventive measures to avoid precipitating factors and prevent recurrent or

recalcitrant infection 5

Dry external auditory canal thoroughly after exposure to moisture or swimming

Avoid self-induced trauma (eg, cleaning ears with foreign objects)

Procedures

Surgical debridement of ear canal 11

General explanation
Surgical removal of debris from the ear canal; usually performed under direct visualization by
otolaryngologist using the open otoscope head, low suction, and instruments dependent on
indication

Anesthesia may be required, depending on extent of debridement required and level of patient
cooperation

Indication
Mainstay of treatment for otomycosis and necrotizing otitis externa
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Use to treat external canal stenosis that does not resolve with aural toilet

Use to treat localized otitis externa requiring extensive incision and drainage of furuncle or
abscess

Contraindications
No absolute contraindications

Complications
Iatrogenic trauma to external auditory canal

Interpretation of results
Culture of any retrieved purulent material is processed for microbial growth and sensitivities

Comorbidities
Patients with underlying immunodeficiency (eg, HIV, diabetes)

Treat with oral antibiotics in addition to topical otic preparation owing to higher risk of
local spread of infection and malignant otitis externa 16

Aggressive debridement is a critical measure

Consider and monitor closely for development of otitis externa; imaging with CT or MRI
may be necessary to confirm diagnosis 23

Consider Aspergillus species as a potential cause 23

Patients with a nonintact tympanic membrane

Treat with non-ototoxic topical preparations 16

Monitoring
Monitor for resolution of symptoms

Persistent severe pain and worsening symptoms that do not improve with 2 to 3 days of
appropriate therapy for acute otitis externa require urgent reevaluation 1 3 23

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Reevaluate for patency of external auditory canal; aural toilet and placement of ear wick
may be required

Reevaluate for the presence of a foreign body 10

Reevaluate patient understanding of administration of ear drop technique and

medication compliance; reevaluate patient compliance with avoidance of modifiable
exacerbating factors (eg, swimming, self-induced trauma to the canal) and prescribed use
of ear drops

Reevaluate for the development of complications (eg, malignant otitis externa, contact
allergy to medication) and alternate diagnosis

Consider ear culture for bacterial and fungal pathogens; addition of a systemic antibiotic
covering Pseudomonas and Staphylococcus species may be required

Consider referral to otolaryngologist for further diagnostic and treatment

recommendations (eg, surgical debridement)

Consider persistence of symptoms beyond 2 weeks a treatment failure that requires

reevaluation 1 2

Reevaluate for alternate diagnosis (eg, malignancy, contact dermatitis, dermatosis of the
external auditory canal)

Consider fungal cause (ie, otomycosis)

Complications and Prognosis

Complications
Malignant (necrotizing) otitis externa  11

Progressive infection of the ear canal with extension of infection into temporal bone and
surrounding structures; results in skull base osteomyelitis and cranial nerve palsies in
advanced infection)

Rare complication of acute bacterial otitis externa; can be life threatening

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Primarily affects patients who are elderly, immunocompromised, or who have poorly
controlled diabetes

Often caused by Pseudomonas aeruginosa

Requires prompt initiation of parenteral antibiotic therapy with or without surgical

debridement

Periauricular cellulitis 15

Acute bacterial infection of the ear canal can progress to facial cellulitis or auricular cellulitis
5

Stenosis of the external auditory canal 32

Can complicate acute severe disease or can result from ongoing chronic infection

Hearing loss 5

Can result from ongoing chronic infection or ototoxicity of ear drops with chronic exposure
to inner ear; can also be secondary to canal obstruction

Chronic otitis externa 11

Can complicate acute otitis externa

Otomycosis

Can result from prolonged use of topical antibiotics 1

More common in patients with immunocompromise or diabetes

Fibrosis of the medial external auditory canal

Can complicate chronic otitis externa

Prognosis
Full recovery with adequate treatment is expected for most patients

Expect rapid symptom improvement given adequate and appropriate treatment for acute otitis
externa

Patients often improve after 1 day of treatment 3

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Most patients experience minimal or no pain after 4 days of treatment

Screening and Prevention

Prevention
Advise patients to avoid excessive moisture and trauma to the auditory canal 11

Acidification with a topical solution of 2% acetic acid is an effective drying technique after
exposure to moisture 5

Application of topical isopropyl alcohol is suggested as an alternate regimen 23

Counsel swimmers on importance of evacuating water from external auditory canal after
swimming (eg, head tilt and gentle ear traction to promote water evacuation) 5

Patient should dry wet ears with a hair dryer on low setting after exposure to moisture 1

Wear soft, malleable ear plugs while swimming 1 23

Patient should avoid manipulation or instrumentation of the external auditory canal to

prevent self-induced trauma; stop frequent ear cleaning, especially with cotton-tipped
applicators 10 5

Ensure that hearing aids are well fitting and removed nightly; avoid hard earplugs owing to
risk of trauma 10 5

Ensure that underlying dermatologic conditions are adequately treated 5

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