Otitis externa medical therapy: Difference between revisions

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Latest revision as of 23:29, 29 July 2020

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:^[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

Otitis externa

1. Otitis externa, acute ^[2]

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^[2]

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^[2]

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]

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)^[3]

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)
↑ ^2.0 ^2.1 ^2.2 ^2.3 Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA; et al. (2014). "Clinical practice guideline: acute otitis externa executive summary". Otolaryngol Head Neck Surg. 150 (2): 161–8. doi:10.1177/0194599813517659. PMID 24492208.
↑ 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)

Template:WH Template:WS

[1] 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)

[pmid24492208-2] 2.0 ^2.1 ^2.2 ^2.3 Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA; et al. (2014). "Clinical practice guideline: acute otitis externa executive summary". Otolaryngol Head Neck Surg. 150 (2): 161–8. doi:10.1177/0194599813517659. PMID 24492208.

[3] 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)

[1]

[2]

[3]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Otitis externa}}
-{{CMG}}; {{AE}} {{MM}}
+{{CMG}}; {{AE}} {{Chi}}; {{Maliha}}; {{PSK}}; {{LRO}}; {{TarekNafee}}
 ==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.
+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==
-Management of otitis externa entails both cleaning the external canal and treating the infection.
+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:<ref>{{Cite journal| doi = 10.1177/0194599813517083| issn = 1097-6817| volume = 150| issue = 1 Suppl| pages = –1-S24| last1 = Rosenfeld| first1 = Richard M.| last2 = Schwartz| first2 = Seth R.| last3 = Cannon| first3 = C. Ron| last4 = Roland| first4 = Peter S.| last5 = Simon| first5 = Geoffrey R.| last6 = Kumar| first6 = Kaparaboyna Ashok| last7 = Huang| first7 = William W.| last8 = Haskell| first8 = Helen W.| last9 = Robertson| first9 = Peter J.| title = Clinical practice guideline: acute otitis externa| journal = Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery| date = 2014-02| pmid = 24491310}}</ref>
+* [[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]]
-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.
+===Otitis externa===
+*'''1. Otitis externa, acute''' <ref name="pmid24492208">{{cite journal| author=Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA et al.| title=Clinical practice guideline: acute otitis externa executive summary. | journal=Otolaryngol Head Neck Surg | year= 2014 | volume= 150 | issue= 2 | pages= 161-8 | pmid=24492208 | doi=10.1177/0194599813517659 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24492208  }} </ref>
+:*'''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'''<ref name="pmid24492208">{{cite journal| author=Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA et al.| title=Clinical practice guideline: acute otitis externa executive summary. | journal=Otolaryngol Head Neck Surg | year= 2014 | volume= 150 | issue= 2 | pages= 161-8 | pmid=24492208 | doi=10.1177/0194599813517659 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24492208  }} </ref>
+:::*Preferred regimen: [[Fluconazole]] 200 mg PO once <u>'''THEN'''</u> [[Fluconazole]] 100 mg PO q24h for 3–5 days
+::*'''1.3.2 Malignant otitis media, Pseudomonas aeruginosa'''<ref name="pmid24492208">{{cite journal| author=Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA et al.| title=Clinical practice guideline: acute otitis externa executive summary. | journal=Otolaryngol Head Neck Surg | year= 2014 | volume= 150 | issue= 2 | pages= 161-8 | pmid=24492208 | doi=10.1177/0194599813517659 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24492208  }} </ref>
+:::*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
-Although the acute external otitis generally resolves in a few days with topical washes and [[antibiotic]]s, 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.
+*'''2. Otitis externa, chronic'''<ref name="pmid24492208">{{cite journal| author=Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA et al.| title=Clinical practice guideline: acute otitis externa executive summary. | journal=Otolaryngol Head Neck Surg | year= 2014 | volume= 150 | issue= 2 | pages= 161-8 | pmid=24492208 | doi=10.1177/0194599813517659 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24492208  }} </ref>
+:*'''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.
-Effective medications include [[ear drop]]s containing [[antibiotic]]s to fight infection, and [[corticosteroid]]s to reduce [[itching]] and [[inflammation]].  External otitis is almost always predominantly [[bacterial]] or predominantly [[fungal]], so that only one type of medication is necessary and indicated.
+==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.
-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.
+==Algorithm for the Approach to Acute Otitis Externa==
+<span style="font-size: 85%;">
+'''Abbreviations''':
+AOE, acute otitis externa;
+TM, tympanic membrane.
+(Adapted from ''Clinical Practice Guideline: Acute Otitis Externa'')<ref>{{Cite journal| doi = 10.1177/0194599813517083| issn = 1097-6817| volume = 150| issue = 1 Suppl| pages = –1-S24| last1 = Rosenfeld| first1 = Richard M.| last2 = Schwartz| first2 = Seth R.| last3 = Cannon| first3 = C. Ron| last4 = Roland| first4 = Peter S.| last5 = Simon| first5 = Geoffrey R.| last6 = Kumar| first6 = Kaparaboyna Ashok| last7 = Huang| first7 = William W.| last8 = Haskell| first8 = Helen W.| last9 = Robertson| first9 = Peter J.| title = Clinical practice guideline: acute otitis externa| journal = Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery| date = 2014-02| pmid = 24491310}}</ref>
+</span>
-====Acute Diffuse Otitis Externa====
+<div style="font-size: 70%;">
+{{Familytree/start}}
-'''Gentle cleansing to remove debris using:'''
+{{Familytree|boxstyle=border: 0;| | | | | X01 | | | | | | | | | | | | | | | | | | | | |X01={{F1|Diffuse AOE}}}}
-*Irrigation with hypertonic saline (3%)
+{{Familytree|boxstyle=border: 0;| | | | | |!| | | | | | | | | | | | | | | | | | | | | |}}
-*Cleansing with mixtures of alcohol (70% to 95%) and acetic acid, should be used initially.
+{{Familytree|boxstyle=border: 0;| | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01={{F2|Analgesic based on severity}}}}
-*Hydrophilic solutions such as 50% [[Burow's solution]] may be used for 1 to 2 days to reduce the inflammation.<ref>{{Cite book  | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 978-0-443-06839-3 | pages =  }}</ref>
+{{Familytree|boxstyle=border: 0;| | | | | |!| | | | | | | | | | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | B01 | | | | | | | | | | | | | | | | | | | | |B01={{F1|Extension beyond ear canal or ⊕ factors requiring systemic Rx?}}}}
-'''Antibiotic use:'''
+{{Familytree|boxstyle=border: 0;| |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | |}}
-{| style="background: #FFFFFF;"
+{{Familytree|boxstyle=border: 0;| C01 | | | | | | C02 | | | | | | | | | | | | | | | | |C01={{F1|YES}}|C02={{F1|NO}}}}
-| valign=top |
+{{Familytree|boxstyle=border: 0;| |!| | | | | | | |!| | | | | | | | | | | | | | | | | |}}
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
+{{Familytree|boxstyle=border: 0;| D01 | | | | | | D02 | | | | | | | | | | | | | | | | |D01={{F2|Abx against ''P. aeruginosa'' and ''S. aureus''}}|D02={{F1|Perforated TM?}}}}
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Acute Diffuse Otitis Externa}}
+{{Familytree|boxstyle=border: 0;| | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | |}}
-|-
+{{Familytree|boxstyle=border: 0;| | | | | E01 | | | | | | E02 | | | | | | | | | | | | |E01={{F1|YES}}|E02={{F1|NO}}}}
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ofloxacin]] 3 drops in ear(s) bid x 7 days'''''
+{{Familytree|boxstyle=border: 0;| | | | | |!| | | | | | | |!| | | | | | | | | | | | | |}}
-|-
+{{Familytree|boxstyle=border: 0;| | | | | F01 | | | | | | F02 | | | | | | | | | | | | |F01={{F2|Non-otoxic topical agent}}|F02={{F2|Topical agent}}}}
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
+{{Familytree|boxstyle=border: 0;| | | | | |`|-|-|-|v|-|-|-|'| | | | | | | | | | | | | |}}
-|-
+{{Familytree|boxstyle=border: 0;| | | | | | | | | G01 | | | | | | | | | | | | | | | | |G01={{F1|Obstructed ear canal?}}}}
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]]-[[dexamethasone]] 3 drops in ear(s) bid x 7 days'''''
+{{Familytree|boxstyle=border: 0;| | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | |}}
-|-
+{{Familytree|boxstyle=border: 0;| | | | | H01 | | | | | | H02 | | | | | | | | | | | | |H01={{F1|YES}}|H02={{F1|NO}}}}
-|}
+{{Familytree|boxstyle=border: 0;| | | | | |!| | | | | | | |!| | | | | | | | | | | | | |}}
-|}
+{{Familytree|boxstyle=border: 0;| | | | | I01 | | | | | | I02 | | | | | | | | | | | | |I01={{F2|Aural toilet or wick placement}}|I02={{F2|Educate pt on how to use ear drops}}}}
-*[[Neomycin]] ear drops alone or with [[polymyxin]] combined with [[hydrocortisone]] are effective in reducing local inflammation and infection.<ref>{{Cite book  | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 978-0-443-06839-3 | pages =  }}</ref>
+{{Familytree|boxstyle=border: 0;| | | | | |`|-|-|-|v|-|-|-|'| | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | | | | | J01 | | | | | | | | | | | | | | | | |J01={{F1|Clinically improve in 3 days?}}}}
-* [[Neomycin]] drops should not be used with perforated [[tympanic membrane]].<ref name="pmid20091565">{{cite journal| author=Kaushik V, Malik T, Saeed SR| title=Interventions for acute otitis externa. | journal=Cochrane Database Syst Rev | year= 2010 | volume=  | issue= 1 | pages= CD004740 | pmid=20091565 | doi=10.1002/14651858.CD004740.pub2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20091565  }} </ref>
+{{Familytree|boxstyle=border: 0;| | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | K01 | | | | | | K02 | | | | | | | | | | | | |K01={{F1|YES}}|K02={{F1|NO}}}}
-====Chronic Otitis Externa====
+{{Familytree|boxstyle=border: 0;| | | | | |!| | | | | | | |!| | | | | | | | | | | | | |}}
-Mostly the cause of chronic otitis externa is irritation from drainage through a perforated [[tympanic membrane]],<ref>{{Cite book  | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 978-0-443-06839-3 | pages =  }}</ref> or a secondary result of [[seborrhea]]. Treatment of chronic otitis externa is directed toward the cause. [[Seborrhea]] is controlled by:
+{{Familytree|boxstyle=border: 0;| | | | | L01 | | | | | | L02 | | | | | | | | | | | | |L01={{F2|Complete Rx course}}|L02={{F1|Illness other than AOE?}}}}
-*[[Selenium sulfide]]
+{{Familytree|boxstyle=border: 0;| | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | |}}
-*[[Ketoconazole]] shampoo + medium potency steroid solution, [[triamcinolone]] 0.1%
+{{Familytree|boxstyle=border: 0;| | | | | | | | | M01 | | | | | | M02 | | | | | | | | |M01={{F1|YES}}|M02={{F1|NO}}}}
+{{Familytree|boxstyle=border: 0;| | | | | | | | | |!| | | | | | | |!| | | | | | | | | |}}
-Other rare cases for chronic otitis externa (e.g [[tuberculosis]], [[syphilis]], [[yaws]], [[leprosy]], and [[sarcoidosis]]) should be treated accordingly.
+{{Familytree|boxstyle=border: 0;| | | | | | | | | N01 | | | | | | N02 | | | | | | | | |N01={{F2|Treat accordingly}}|N02={{F2|Assess Rx adherence/delivery}}}}
+{{Familytree/end}}
-====Malignant Otitis Externa====
+</div>
-{| style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 500px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Pseudomonas Aeruginosa}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 400 mg IV q8h'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Imipenem]] 0.5 gm IV q6h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Meropenem]] 1 gm IV q8h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftazidime]] 2 gm IV q8h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 2 gm IV q12h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Piperacillin/tazobactam]] 4.5 gm IV q6h'''''<BR>PLUS<BR>▸ '''''[[Tobramycin]] 5.1 mg/kg q24h or 2 mg loading dose, then 1.7 mg/kg q8h'''''
-|-
-|}
-|}
-*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.<ref name="pmid17205441">{{cite journal| author=Lodise TP, Lomaestro B, Drusano GL| title=Piperacillin-tazobactam for Pseudomonas aeruginosa infection: clinical implications of an extended-infusion dosing strategy. | journal=Clin Infect Dis | year= 2007 | volume= 44 | issue= 3 | pages= 357-63 | pmid=17205441 | doi=10.1086/510590 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17205441  }} </ref>
-====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.<ref>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 </ref>
-==Contraindicated medications==
-{{MedCondContrAbs
-|MedCond = Viral otitis externa|Ciprofloxacin and dexamethasone otic suspension}}
 ==References==
 {{reflist|2}}
-[[Category:Primary care]]
+{{WH}}
+{{WS}}
 [[Category:Disease]]
+[[Category:FinalQCRequired]]
+[[Category:Emergency mdicine]]
+[[Category:Up-To-Date]]
 [[Category:Infectious disease]]
-[[Category:Inflammations]]
 [[Category:Otolaryngology]]
 [[Category:Pediatrics]]
+[[Category:Immunology]]