OTITIS EXTERNA
PREVENTION
Advise patients to refrain from excessive manipulation or cleaning of the external ear
canal.

Discuss with parents the naturally bacteriostatic environment of the ear canal and the
risks of instrumentation, particularly with cotton swabs.
Advise patients to prevent or reduce excess moisture in the ear canal.

Consider advising patients, especially in humid climates, to either avoid water sports
or to consider the use of drying agents (primarily alcohol-based agents) only when
repeated, significant episodes of external otitis are a problem.

Note that protective devices such as ear plugs are necessary only in patients with
recurrent episodes
DIAGNOSIS
Consider the diagnosis of otitis externa in patients with otalgia, ear discharge, or
pruritus and pain on manipulation of the auricle.

Ask about:

Water exposure

History of trauma or manipulation

Diabetes mellitus

Immunocompromised state

Dermatitis of the external auditory canal

Otalgia, or pain with chewing

Ear discharge

Ear fullness

Pruritus

Hearing loss (conductive)
Examine the ear for evidence of infection localized to external auditory canal.

Look for:

Erythema

Edema

Discharge (may be scant)

Exfoliated skin or squamous debris

Thickened epithelium or “cobblestone” appearance of the skin

Interruption of the tympanic membrane or the presence of tympanostomy
tubes
DIAGNOSTIC TESTS
Consider microbiologic and/or radiologic studies in patients presenting with unusual
symptoms and signs and in those who are refractory to prior treatment.

Note that no lab or radiographic tests are needed at outset and treatment is initiated
based on clinical findings.

Perform microbiological tests to identify the organism and appropriate therapy in
persistent otitis externa.

Perform radiologic studies such as CT of the temporal bone with evidence of bone
cancer or MRI of the head in patients with unusual symptoms and signs such as
severe headache, vertigo, or nystagmus, or in patients with refractory otitis externa
symptoms who are immunocompromised or have diabetes mellitus.
Consider other infectious, inflammatory, or neoplastic processes involving the skin, soft
tissue, cartilage, or bone surrounding the auditory canal.

Be aware that any dermatologic disorder can potentially manifest itself in the ear.

Recognize that otitis externa can encompass a broad spectrum of disease processes
ranging from local bacterial infections such as furunculosis to invasive, potentially
systemic MOE(malignant otitis externa)

Consider other diagnoses when otitis externa fails to resolve with appropriate therapy
or when specific history or findings suggest a more likely diagnosis.
CONSULTATION
Consider consulting an otolaryngologist if clinical findings suggest complex or atypical
disease.

Consider consulting an otolaryngologist when the diagnosis is unclear based on
unusual history or findings on physical exam, such as:

TM perforation

Exposed bone

Abundant granulation tissue

Cholesteatoma

Significant canal wall erosion
Consider consultation for management in all patients who require extensive
management beyond ototopical antibiotics.

Refer to an otolaryngologist:

When refractory otorrhea prevents adequate visualization of the tympanic
membrane

For aggressive aural toilet using suction debridement under microscope or for
wick placement

For surgical management including incision and drainage or debridement
HOSPITALIZATION
Hospitalize patients when systemic or significant local complications of otitis externa
such as cellulitis are present.

Hospitalize patients with fever or evidence of cellulitis beyond the ear canal for
antibiotic therapy.
THERAPY
Relieve obstruction of the ear canal.

Under direct vision with otoscope, carefully apply a cerumen wire, cotton-tipped swab,
or unraveled cotton ball to the external canal to promote removal of debris and
otorrhea as needed.

Consider referral to otolaryngologist for suction debridement under microscopic
visualization when initial standard therapy fails.
Use ototopical agents as first-line treatment of uncomplicated otitis externa.

Use topical agents as first-line therapy for uncomplicated disease.

Consider:

Acetic acid with or without hydrocortisone

Ciprofloxacin with or without a corticosteroid (More rapid relief of symptoms than topical
antibiotics alone)


Ofloxacin

Neomycin (Ototoxicity with neomycin if used with tympanic membrane perforation or if used longterm), polymyxin, and hydrocortisone
Use quinolone in patients with tympanostomy tubes or perforated tympanic
membranes.
Treat with oral or intravenous antibiotics only in patients whose infection has spread
beyond the ear canal.

Use systemic antibiotics if infection has spread beyond the external canal.

Consider systemic antibiotics in patients who are at increased risk for complications,
including those with uncontrolled diabetes or who are immunocompromised.
Treat pain in patients with otitis externa.

Treat pain in patients with otitis externa.

Note that pain may be severe.

Consider treatment with:

An oral NSAID or acetaminophen

A topical steroid

An opioid in patients with severe pain
Select the form of topical therapy based on patient factors.

Maximize therapeutic benefit by choosing an appropriate drug form and delivery
mechanism.

Consider ototopical spray before drops for superior patient tolerance and clinical
response.
Advise patients to restore and maintain normal ear physiology.

Advise patients to avoid water exposure and instrumentation of ear.

Consider acidifying drops to reduce pH and inhibit bacterial growth.
Consider desiccating solutions for residual moisture, as persistent
moisture may lead to prolongation of infection and potential for fungal
overgrowth.
PATIENT COUNSELLING
Inform patients with otitis externa about clinical course, importance of
adherence to therapy, potential complications, and secondary prevention.

Advise patients:

To use drops for 7 to 10 days or longer depending on physician
recommendations

To keep follow-up appointments for debridement to aid in drop
delivery and time to cure

That most cases of external otitis resolve within 7 to 10 days

That follow-up is important to ensure resolution of disease and to
allow the clinician to eliminate other diagnoses in cases of
persistent disease
FOLLOW UP
Follow the patient until resolution of disease is confirmed.


Schedule follow-up:

As frequently as every other day or at least once a week to ensure
resolution of disease

To remove debris and facilitate drop placement

To confirm appropriate response to therapy as persistent disease
may require further work-up to investigate alternative diagnoses
Refer patients with nonresponsive or recurrent disease to a specialist for
suction debridement under the operative microscope, wick placement, or
examination for other underlying disease.

Elements of Follow-up for Otitis Externa