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Practice Point

Acute otitis externa

Charles PS Hui; Canadian Paediatric Society, Infectious Diseases and Immunization
Franais en page 99

Cps Hui; Canadian paediatric society, infectious Diseases and lotite externe aigu
immunization Committee. acute otitis externa. paediatr Child
Health 2013;18(2):96-98. Lotite externe aigu, ou otite du baigneur, est une maladie courante
chez les enfants, les adolescents et les adultes. Lotite moyenne
Acute otitis externa, also known as swimmers ear, is a common dis- suppurative chronique et lotite moyenne aigu corrige par des tubes
ease of children, adolescents and adults. While chronic suppurative de tympanostomie ou accompagne dune perforation peuvent tre
otitis media or acute otitis media with tympanostomy tubes or a perfo- responsables dune otite externe aigu, mais tant les organismes
ration can cause acute otitis externa, both the infecting organisms and infectieux que le protocole de prise en charge diffrent. Le prsent
management protocol are different. This practice point focuses solely point de pratique porte exclusivement sur la prise en charge de lotite
on managing acute otitis externa, without acute otitis media, tym- externe aigu sans prsence concomitante dotite moyenne aigu, de
panostomy tubes or a perforation being present. tubes de tympanostomie ou de perforation.

Key Words: Acute otitis externa; Swimmers ear

A cute otitis externa (AOE), also known as swimmers ear, is a

common disease of children, adolescents and adults. It is
defined by diffuse inflammation of the external ear canal. Primarily
WITH OR WITHOUT hearing loss or jaw pain (Pain in
the ear canal and temporomandibular joint region
intensified by jaw motion [4])
a disease of children over two years of age, it is commonly associ- AND
ated with swimming. Local defence mechanisms become impaired
3. Signs of ear canal inflammation, including
by prolonged ear canal wetness. Skin desquamation leads to micro-
scopic fissures that provide a portal of entry for infecting organ- tenderness of the tragus, pinna, or both
isms.(1) Other risk factors for AOE include: trauma, a foreign body OR
in the ear, using a hearing aid, certain dermatological conditions, diffuse ear canal edema, erythema, or both
chronic otorrhea, wearing tight head scarves and being immuno-
compromised. Ear piercing may lead to infection of the pinna.(2,3) WITH OR WITHOUT otorrhea, regional lymphadenitis,
While AOE is primarily a local disease, more serious and invasive tympanic membrane erythema, or cellulitis of the pinna
disease can occur in certain situations. Several evidence-based and adjacent skin
clinical practice guidelines and reviews have been published.
etiologiCal organisms
Infection causes the vast majority of AOE cases. The two most
CliniCal presentation commonly isolated organisms are Pseudomonas aeruginosa and
Typically, patients present with otalgia (70%), itching (60%) or Staphylococcus aureus.(9) The isolates are polymicrobial in a sig-
fullness (22%), with or without hearing loss (32%) or ear canal nificant number of cases. Other Gram-negative bacteria are less
pain when chewing. Many patients with AOE have discharge from common. Rare fungal infections have been described with
their ear canal. A distinguishing sign of AOE from acute otitis Aspergillus species and Candida species.(10) Swabs from the exter-
media with otorrhea is the finding of tenderness of the tragus when nal canal should be interpreted with caution because they may
pushed and of the pinna when pulled in AOE. These signs are clas- reflect normal flora or colonizing organisms. Swabs should be
sically described as out of proportion to the degree of inflammation taken only in unresponsive or severe cases.
observed. On direct otoscopy, the canal is edematous and ery-
thematous and may be associated with surrounding cellulitis.(4)
The management of AOE has been the subject of one Cochrane
There may be cellulitis or chondritis of the pinna.
systematic review (updated 2010) ,(8) one meta-analysis by the
Elements to consider in the diagnosis of diffuse acute otitis
American Academy of Otolaryngology-Head and Neck Surgery
(AAO-HNS) (11), and one clinical practice guideline (AAO-HNS)
1. Rapid onset (generally within 48 h) in the past three weeks (4). The Cochrane publication reviewed 19 studies that included
AND 3382 participants. Overall, only three of the 19 studies were con-
2. Symptoms of ear canal inflammation, including sidered to be of high quality and only two were performed in a pri-
mary care setting. Similar findings were reached in the AAO-HNS
otalgia (often severe), itching or fullness meta-analysis and are reflected in the practice guideline.

Correspondence: Canadian Paediatric Society, 2305 St Laurent Boulevard, Ottawa, Ontario K1G 4J8. E-mail info@cps.ca, website www.cps.ca

96 2013 Canadian Paediatric Society. All rights reserved Paediatr Child Health Vol 18 No 2 February 2013
CPS Practice Point

It is clear that topical antimicrobials are effective in mild-to- Table 1

moderate AOE. No randomized control trials have been published Medications available in Canada for acute otitis externa
comparing topical to systemic antimicrobials. Topical antimicrob- Dosing and duration as per the
ials increased absolute clinical cure rates of AOE by 46% and brand name active ingredients product monograph
bacteriological cure rates by 61% compared with placebo.(11) Polysporin plus Polymyxin B sulfate Three to four drops four times/day
There seemed to be minimal to no difference in clinical or bac- pain relief ear lidocaine HCl Infants and children, two to three
teriological cure rate for the addition of topical steroids to topical drops*, drops are suggested.
antimicrobials, although the quality of these studies was poor. Solution may be applied by
(4,12) A systematic review showed that in a combined total of saturating a gauze or cotton
only 92 patients there was a slight superiority of topical steroids wick which may be left in the
canal for 24 h to 48 h, keeping
compared with topical steroids and topical antimicrobials for clin-
the wick moist by adding a
ical cure at seven to 11 days. Topical acidifying solutions (eg, Buro-
few drops of solution as
Sol) have also been shown to be equally effective as topical required.
antimicrobials in clinical cure rates at one week, but inferior in No duration stated
clinical and microbiological cure at two to three weeks. Topical
Polysporin eye/ Polymyxin B sulfate One to two drops four times/day,
antiseptics such as alcohol, gentian violet, m-Cresyl acetate, thi- ear drops*, gramicidin or more frequent as required
merosal and thymol have been shown in small studies to be equally No duration stated
effective as topical antimicrobials but are not specifically marketed Neosporin eye Polymyxin B sulphate One to two drops two to four
in Canada for treatment of AOE. and ear times/day for seven days
Neomycin sulphate
Ototoxic topical agents such as gentamicin or neomycin, agents solution*, Gramicidin
with a low pH (including most acidifying and antiseptic agents), or
Cortisporin otic Neomycin sulfate Four drops three to four times/day
Cortisporin (Johnson & Johnson Inc, USA) topical drops should solution polymyxin B sulfate No duration stated
not be used in the presence of tympanostomy tubes or a perforated sterile*,, hydrocortisone
tympanic membrane because there is an increasing body of literature Sofracort*, Framycetin sulfate Two to three drops three to
concerning ototoxicity in both settings.(13) These agents should gramicidin four times/day
also not be used if the tympanic membrane cannot be seen. dexamethasone No duration stated
For treating mild-to-moderate acute otitis externa, the follow- Ciprodex** Ciprofloxacin HCl Four drops twice/day for seven
ing steps are recommended: dexamethasone days
1. First line therapy for mild-to-moderate AOE should be a Buro-Sol otic Aluminum acetate Two to three drops three to four
topical antibiotic with or without topical steroids for seven to solution*,, benzethonium chloride times/day
10 days.(4) More severe cases should be managed with Acetic acid No duration stated
systemic antibiotics that cover S aureus and P aeruginosa. Garasone otic Gentamicin- Three to four drops threes
solution*, betamethasone times/day
2. Adequate pain control for mild-to-moderate AOE can be
No duration stated
achieved with systemic acetaminophen, nonsteroidal anti-
inflammatory medications or oral opioid preparations. Topical Garamycin otic Gentamicin sulfate Three to four drops three times/
drops*, day
steroid preparations have had mixed effects on hastening pain
No duration stated
relief in clinical trials and cannot be recommended as
*Should not be used in patients with a nonintact tympanic membrane;
monotherapy. Johnson & Johnson Inc, USA; GlaxoSmithKline, United Kingdom; sanofi-
3. If the clinician cannot see the ear canal, an expandable wick aventis Canada Inc, Canada; Alcon Canada Inc, Canada; **Off-label use;
can be placed to decrease canal edema and facilitate topical Stiefel Canada Inc, Canada; Merck Canada Inc, Canada

medication delivery.(14) Although aural toileting and wick

therapy are common and logical practices, there have been no
randomized controlled trials examining their effectiveness. Ear
candling has been shown to have no efficacy and can be
harmful.(15) prevention
Clinical response should be evident within 48 h to 72 h,(16) Targeting typical causal culprits of AOE, such as moisture and
but full response can take up to six days in patients treated with trauma, seems prudent. Some experts recommend simple tech-
antibiotic and steroid drops.(8) Nonresponse should prompt an niques for keeping water out of the ears (eg, inserting a soft, mal-
evaluation for obstruction, the presence of a foreign body, non- leable plug into the auricle to block entry to the ear canal) or
adherence to therapy or an alternative diagnosis (eg, dermatitis removing water from the ears after swimming (by positioning or
from contact with nickel, a viral or fungal infection or antimicrob- shaking the head, or by using a hair dryer on a low setting).
ial resistance). Others advise avoiding cotton swabs because they might impact
malignant otitis externa cerumen. Daily prophylaxis with alcohol or acidic drops during
In patients who are immunodeficient or who have insulin-dependent at-risk activities has also been suggested but not studied. Using
diabetes, special measures should be taken to rule out malignant hard earplugs should be avoided because they can cause trauma,
otitis externa. This invasive infection of the cartilage and bone of and the use of custom ear canal molds and tight swim caps
the canal and external ear may present with facial nerve palsy and remains controversial.(5)
pain as a prominent symptom. Imaging with a computed tomog-
raphy or magnetic resonance imaging scan may be needed to con- aCKnoWleDgements: This practice point has been reviewed
firm the clinical diagnosis.(17) Aggressive debridement with by the Community Paediatrics and Drug Therapy and Hazardous
systemic antibiotics targeted at P aeruginosa, and in some cases Substances Committees of the Canadian Paediatric Society.
Aspergillus species, is critical.

Paediatr Child Health Vol 18 No 2 February 2013 97

CPS Practice Point

reFerenCes 10. Martin TJ, Kerschner JE, Flanary VA. Fungal causes of otitis externa
1. Wright DN, Alexander JM. Effect of water on the bacterial flora of and tympanostomy tube otorrhea. Int J Pediatr Otorhinolaryngol
swimmers ears. Arch Otolaryngol 1974;99(1):15-8. 2005;69(11):1503-8.
2. Rowshan HH, Keith K, Baur D, Skidmore P. Pseudomonas aeruginosa 11. Rosenfeld RM, Singer M, Wasserman JM, Stinnett SS. Systematic
infection of the auricular cartilage caused by high ear piercing: review of topical antimicrobial therapy for acute otitis externa.
A case report and review of the literature. J Oral Maxillofac Surg Otolaryngol Head Neck Surg 2006;134(4 Suppl):S24-48.
2008;66(3):543-6. 12. Msges R, Domrse CM, Lffler J. Topical treatment of acute otitis
3. Keene WE, Markum AC, Samadpour M. Outbreak of Pseudomonas externa: Clinical comparison of an antibiotics ointment alone or in
aeruginosa infections caused by commercial piercing of upper ear combination with hydrocortisone acetate. Eur Arch Otorhinolaryngol
cartilage. JAMA 2004 25;291(8):981-5. 2007;264(9):1087-94.
4. Rosenfeld RM, Brown L; American Academy of Otolaryngology 13. Stockwell, M. Gentamicin ear drops and ototoxicity: Update.
Head and Neck Surgery Foundation, et al. Clinical practice CMAJ 2001;164(1):93-4.
guideline: Acute otitis externa. Otolaryngol Head Neck Surg 14. Otitis externa. In Cummings CW, Flint PW, Haughey BH, et al.
2006;134(4 Suppl):S4-23. Otolaryngology: Head and Neck Surgery, 4th edn. Philadelphia:
5. Osguthorpe JD, Nielsen DR. Otitis externa: Review and clinical Mosby, 2005.
update. Am Fam Physician 2006;74(9):1510-6. 15. Seely DR, Quigley SM, Langman AW. Ear candles: Efficacy and
6. McKean SA, Hussain SSM. Otitis externa. Clinical Otolaryngology safety. Laryngoscope 1996;106(10):1226-9.
2007;32(6):457-9. 16. van Balen FA, Smit WM, Zuithoff NP, Verheij TJ. Clinical efficacy
7. Stone KE, Serwint JR. Otitis externa. Pediatr Rev 2007;28(2):77-8. of three common treatments in acute otitis externa in primary care:
8. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis Randomised controlled trial. BMJ 2003;327(7425):1201-5.
externa. Cochrane Database Syst Rev 2010;1:CD004740. 17. Rubin Grandis J, Branstetter BF 4th, Yu VL. The changing face of
9. Roland PS, Stroman DW. Microbiology of acute otitis externa. malignant (necrotizing) external otitis: Clinical, radiological, and
Laryngoscope 2002;112(7):1166-77. anatomic correlations. Lancet Infect Dis 2004;4(1):34-9.

Cps inFeCtioUs Diseases anD immUniZation Committee

members: Robert Bortolussi MD; Natalie A Bridger MD; Jane C Finlay MD; Susanna Martin MD (Board Representative); Jane C McDonald MD;
Heather Onyett MD; Joan Louise Robinson MD (Chair)
liaisons: Upton D Allen MD, Canadian Pediatric AIDS Research Group; Michael Brady MD, Committee on Infectious Diseases, American
Academy of Pediatrics; Janet Dollin MD, College of Family Physicians of Canada; Charles PS Hui MD, Committee to Advise on Tropical Medicine
and Travel, Public Health Agency of Canada; Nicole Le Saux MD, Immunization Monitoring Program, ACTive (IMPACT); Dorothy L Moore MD,
National Advisory Committee on Immunization (NACI); John S Spika MD, Public Health Agency of Canada
Consultant: Noni E MacDonald MD
principal author: Charles PS Hui MD

The recommendations in this document do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account indi-
vidual circumstances, may be appropriate. All Canadian Paediatric Society position statements and practice points are reviewed on a regular basis. Please
consult the Position Statements section of the CPS website (www.cps.ca) for the full-text, current version.

98 Paediatr Child Health Vol 18 No 2 February 2013

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