Otitis externa medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The goal of treatment is to cure the infection and to return the ear canal skin to a healthy condition. When external otitis is very mild, in its initial stages, simply refraining from swimming or washing hair for a few days, and keeping all implements out of the ear, usually results in cure. For this reason, external otitis is called a self-limiting condition. However, if the infection is moderate to severe, or if the climate is humid enough that the skin of the ear remains moist, spontaneous improvement may not occur.
Medical Therapy
Pharmacotherapy
Topical solutions or suspensions in the form of ear drops are the mainstays of treatment for external otitis. Some contain antibiotics, either antibacterial or antifungal, and others are simply designed to mildly acidify the ear canal environment to discourage bacterial growth. Some prescription drops also contain anti-inflammatory steroids, which help to resolve swelling and itching. Although there is evidence that steroids are effective at reducing the length of treatment time required, otitis externa (also called otomycosis) may be caused or aggravated by overly prolonged use of steroid-containing drops. In addition to topical antibiotics, oral anti-pseudomonal antibiotics can be used in case of severe soft tissue swelling extending into the face and neck and may hasten recovery.
Removal of debris (wax, shed skin, and pus) from the ear canal promotes direct contact of the prescribed medication with the infected skin and shortens recovery time. This is best accomplished using a binocular microscope. When canal swelling has progressed to the point where the ear canal is blocked, topical drops may not penetrate far enough into the ear canal to be effective. The physician may need to carefully insert a wick of cotton or other commercially available, pre-fashioned, absorbent material called an ear wick and then saturate that with the medication. The wick is kept saturated with medication until the canal opens enough that the drops will penetrate the canal without it. Removal of the wick does not require a health professional. Antibiotic ear drops should be dosed in a quantity that allows coating of most of the ear canal and used for no more than 4 to 7 days. The ear should be left open. Do note that it is imperative that there is visualization of an intact tympanic membrane. Use of certain medications with a ruptured tympanic membrane can cause tinnitus, vertigo, dizziness, and hearing loss in some cases.
Although the acute external otitis generally resolves in a few days with topical washes and antibiotics, complete return of hearing and cerumen gland function may take a few more days. Once healed completely, the ear canal is again self-cleaning. Until it recovers fully, it may be more prone to repeat infection from further physical or chemical insult.
Effective medications include ear drops containing antibiotics to fight infection, and corticosteroids to reduce itching and inflammation. In painful cases a topical solution of antibiotics such as aminoglycoside, polymyxin, or fluoroquinolone is usually prescribed. External otitis is almost always predominantly bacterial or predominantly fungal, so that only one type of medication is necessary and indicated.
The pain of acute otitis externa is often severe enough to interfere with sleep. Topical analgesic drops often prescribed by primary care providers for pain relief are almost never adequate and should not be relied upon. A brief course of oral narcotic pain medication is often necessary to maintain comfort while the antibiotic drops are working. Improvement with appropriate initial treatment (cleaning of the canal, wick insertion if necessary, and antibiotic drops in adequate amount) is fairly rapid, with pain improvement occurring within one day and resolution within 2-4 days. Heat application using a heating pad, can also aid in pain relief.
Acute Diffuse Otitis Externa
Gentle cleansing to remove debris using:
- Irrigation with hypertonic saline (3%)
- Cleansing with mixtures of alcohol (70% to 95%) and acetic acid, should be used initially.
- Hydrophilic solutions such as 50% Burrow’s solution may be used for 1 to 2 days to reduce inflammation.[1]
Antibiotics use:
- Fluoroquinolone otic solution such as ofloxacin, ciprofloxacin-dexamethasone otic, or neomycin ear drops alone or with polymyxin combined with hydrocortisone are effective in reducing local inflammation and infection.[2]
Chronic Otitis Externa
Mostly the cause of chronic otitis externa is irritation from drainage through a perforated tympanic membrane,[3] or a secondary result of seborrhea. Treatment chronic otitis externa is directed toward the cause.
Other rare cases for chronic otitis externa (e.g tuberculosis, syphilis, yaws, leprosy, and sarcoidosis) should be treated accordingly.
Malignant Otitis Externa
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- For other pathogens, treatment should be guided by the culture and susceptibility test.
- Surgical debridement is indicated along with antibiotics use.
- In case of pseudomonas aeruginosa infections, extended infusion of piperacillin/tazobactam (4-hr infusion of 3.375 gm q8h) may improve treatment efficacy.[4]
Fungal Otitis Externa
- Fluconazole 200 mg po x 1 dose, then 100 mg po x 3-5 days.
Non-Prescription Remedies
Provided it is not too severe, recurrent otitis externa can often be successfully treated by non-prescription means, at low cost. When symptoms recur in an individual who has had a previous diagnosis made, the use of non-prescription drops along with precautions to keep water out of the ear is generally effective. Self-treatment with non-prescription remedies is dangerous in individuals who have not been previously evaluated for the condition, because the tympanic membrane may not be intact, and because the true condition may be otitis media with drainage. Drops and water precautions may actually resolve otitis media with drainage for a period of time, while allowing an undiagnosed cholesteatoma to progress, or complications of otitis media to develop.
Effective solutions for the ear canal include acidifying and drying agents, used either singly or in combination. When the ear canal skin is inflamed from the acute otitis externa, the use of dilute acetic acid may be painful.
Burow's solution is an effective remedy against both bacterial and fungal external otitis. This is a buffered mixture of aluminum sulfate and acetic acid, and is available without prescription in the United States.[5]
References
- ↑ Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 978-0-443-06839-3.
- ↑ Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 978-0-443-06839-3.
- ↑ Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 978-0-443-06839-3.
- ↑ Lodise TP, Lomaestro B, Drusano GL (2007). "Piperacillin-tazobactam for Pseudomonas aeruginosa infection: clinical implications of an extended-infusion dosing strategy". Clin Infect Dis. 44 (3): 357–63. doi:10.1086/510590. PMID 17205441.
- ↑ Kashiwamura M. Chida E. Matsumura M. Nakamaru Y. Suda N. Terayama Y. Fukuda S. The efficacy of Burow's solution as an ear preparation for the treatment of chronic ear infections. [Clinical Trial. Journal Article] Otology & Neurotology. 25(1):9-13, 2004