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| ==Overview== | | ==Overview== |
| Management of otitis externa includes both cleaning the external canal and treating the infection. 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. | | Management of otitis externa includes both cleaning the external canal and treating the infection. Wh |
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| ==Medical Therapy== | | ==Medical Therapy== |
| 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.
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| Gentle cleansing to remove debris using:
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| *Irrigation with hypertonic saline (3%)
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| *Cleansing with mixtures of alcohol (70% to 95%) and acetic acid, should be used initially.
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| *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>
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| ==Antibiotic Therapy== | | ==Antibiotic Therapy== |
| 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.
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| ===Acute Otitis Externa=== | | ===Acute Otitis Externa=== |
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| ! 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}}
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ofloxacin]] 3 drops in ear(s) bid x 7 days'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]]-[[dexamethasone]] 3 drops in ear(s) bid x 7 days'''''
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| *[[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>
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| * [[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>
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| ===Malignant Otitis Externa=== | | ===Malignant Otitis Externa=== |
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| ! 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}}
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 400 mg IV q8h'''''
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Imipenem]] 0.5 gm IV q6h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Meropenem]] 1 gm IV q8h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftazidime]] 2 gm IV q8h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 2 gm IV q12h'''''
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| | 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'''''
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| *For other pathogens, treatment should be guided by the culture and susceptibility test.
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| *Surgical debridement is indicated along with antibiotics use.
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| *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>
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| ===Fungal Otitis Externa=== | | ===Fungal Otitis Externa=== |
| *[[Fluconazole]] 200 mg po x 1 dose, then 100 mg po x 3-5 days.
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| ===Chronic Otitis Externa=== | | ===Chronic Otitis Externa=== |
| 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:
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| *[[Selenium sulfide]]
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| *[[Ketoconazole]] shampoo + medium potency steroid solution, [[triamcinolone]] 0.1%
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| Other rare cases for chronic otitis externa (e.g [[tuberculosis]], [[syphilis]], [[yaws]], [[leprosy]], and [[sarcoidosis]]) should be treated accordingly.
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| ==Pain Management== | | ==Pain Management== |
| Pain associated with AOE can be intense and severe requiring administration of analgesic agents. 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. | | Pain associated with AOE can be intense and severe requiring administration of analgesic agents. |
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| ==Non-Prescription Remedies==
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| 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.
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| 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.
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| 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.
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| [[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>
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| ==Contraindicated medications== | | ==Contraindicated medications== |