Acute Otitis Externa

Acute Otitis Externa – Treatment Options

Introduction
Acute otitis externa (AOE), also called “swimmer’s ear,” is an acute infection and inflammation of the external auditory canal. It is commonly caused by bacterial pathogens, particularly Pseudomonas aeruginosa and Staphylococcus aureus. Risk factors include water exposure, trauma from cotton swabs or hearing aids, humid environments, and underlying dermatologic conditions (eczema, psoriasis). Symptoms include ear pain, itching, swelling, discharge, and tenderness with manipulation of the tragus or pinna.

1. General and Supportive Measures

• Ear canal cleaning (aural toilet): Removal of debris, cerumen, and discharge to allow effective topical therapy.

• Keep ear dry: Avoid swimming and protect the ear during bathing or showering.

• Analgesia: Oral NSAIDs (ibuprofen) or acetaminophen for pain relief.

2. Topical Therapy (First-Line Treatment)

• Topical antibiotic ear drops (± corticosteroid):

  • Ciprofloxacin/dexamethasone or ciprofloxacin/hydrocortisone.

  • Ofloxacin drops (safe in cases with tympanic membrane perforation).

  • Neomycin/polymyxin B/hydrocortisone drops (avoid if perforation suspected due to ototoxicity risk).

• Acetic acid or alcohol-based drops: Mild cases, restore acidic environment that inhibits bacterial growth.

• Duration: Typically 7–10 days.

3. Systemic Therapy (Reserved for Severe or Complicated Cases)

• Oral antibiotics: Indicated if infection extends beyond ear canal (cellulitis, fever, immunocompromised state).

  • Agents: Fluoroquinolones (ciprofloxacin) for suspected Pseudomonas.

• Hospitalization/IV therapy: For malignant (necrotizing) otitis externa, particularly in elderly diabetics or immunocompromised patients.

4. Complication Management

• Malignant otitis externa: Aggressive IV antipseudomonal therapy (ciprofloxacin, ceftazidime, or piperacillin–tazobactam), often prolonged for 6–8 weeks. Requires ENT involvement.

• Abscess formation: Incision and drainage if localized fluctuant swelling.

• Hearing impairment: Temporary; resolves after infection subsides.

5. Lifestyle and Preventive Measures

• Avoid inserting objects (cotton swabs, hairpins) into the ear canal.

• Use earplugs or custom-molded devices for swimmers.

• Dry ears after swimming with a towel or hair dryer on cool setting.

• Acidifying drops (2% acetic acid) as prophylaxis in recurrent swimmers.

6. Multidisciplinary Care

• Primary care physicians: For diagnosis and first-line management.

• ENT specialists: For severe, recurrent, or complicated cases.

• Infectious disease specialists: For malignant otitis externa requiring long-term IV antibiotics.