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Otitis externa

The right clinical information, right where it's needed

Last updated: Nov 30, 2017


Table of Contents
Summary 3

Basics 4
Definition 4
Epidemiology 4
Etiology 4
Pathophysiology 5
Classification 5

Prevention 6
Primary prevention 6
Secondary prevention 6

Diagnosis 7
Case history 7
Step-by-step diagnostic approach 7
Risk factors 8
History & examination factors 10
Diagnostic tests 10
Differential diagnosis 12

Treatment 14
Step-by-step treatment approach 14
Treatment details overview 16
Treatment options 18

Follow up 34
Recommendations 34
Complications 34
Prognosis 35

Guidelines 36
Treatment guidelines 36

Evidence scores 37

References 38

Images 42

Disclaimer 43
Summary

◊ Most commonly caused by Pseudomonas aeruginosa and Staphylococcus species.

◊ Presents with rapid onset of ear pain, tenderness, itching, aural fullness, and hearing loss.

◊ The development of malignant or necrotizing otitis externa is more common in diabetic and
immunocompromised people.

◊ Treatment of the uncomplicated form is cleaning of the ear canal and application of topical anti-
infective agents.
Otitis externa Basics

Definition
Acute otitis externa (AOE) is defined as diffuse inflammation of the external ear canal, which may also
involve the pinna or tympanic membrane.[1] It is a form of cellulitis that involves the skin and subdermis of
BASICS

the external auditory canal, with acute inflammation and variable edema.[1] It is most commonly caused by
bacterial infection. The diagnosis of AOE requires the presence of rapid onset (generally within 48 hours) of
symptoms within the past 3 weeks, coupled with signs of ear canal inflammation.[1]

Diagram of acute otitis externa


Created by the BMJ Knowledge Centre

Epidemiology
AOE has a lifetime incidence of 10%.[1] In another review article it was mentioned that AOE affects 4 in
1000 people annually in the US.[7] The condition is known to affect people of all age groups but was found
to peak in the 7- to 12-year-old age group and to decline in incidence among subjects >50 years of age.[8]
In a study done in the UK, the 12-month prevalence of otitis externa was >1% and its prevalence was higher
for females than for males up to the age of 65 years.[9] In the same study, the incidence of otitis externa
increased toward the end of the summer, especially in the youngest age group (5-19 years old). It is common
in warmer temperatures and high-humidity conditions and after swimming.

Etiology
Most commonly caused by bacterial infections. It is often polymicrobial, but the most common pathogens are
Pseudomonas aeruginosa (20%-60% prevalence) and Staphylococcus aureus (10%-70% prevalence).[1]
Other etiologies are idiopathic, trauma (from scratching, aggressive cleaning), chemical irritants, allergy
(most commonly to antibiotic ear drops such as neomycin), high-humidity conditions, swimming, or skin
disease (allergic dermatitis, atopic dermatitis, psoriasis).[2]

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Otitis externa Basics

Pathophysiology
The causes or pathogenesis are usually multifactorial. Several risk factors can predispose to infection or
initiate inflammation and subsequently the infectious process. Intact canal skin and cerumen production

BASICS
have a protective effect against infections. This is secondary to the fact that cerumen produces a pH in the
ear canal that is slightly acidic.[1] [7] On the other hand, breakdown of skin integrity, insufficient cerumen
production, or blockage of the ear canal with cerumen (which promotes water retention) can predispose
to infection. Skin integrity can be injured by direct trauma, heat, and moisture or persistent water in the
ear canal. Such damage is thought to be necessary for initiation of the inflammatory process.[3] [10]
Subsequently, edema may result, followed by bacterial inoculation and overgrowth.

Classification
Scot t and Brown[2]
No official classification system has been published, and different authors have classified otitis externa
differently. Perhaps the most detailed classification system is as follows:

Localized otitis externa (furunculosis): localized infection in the hair follicles in the cartilaginous portion of the
external auditory canal.[3]

Diffuse otitis externa: infection is limited to the skin of the external auditory canal and concha, and possibly
the tympanic membrane.

Part of a generalized skin condition: patients have other skin conditions such as seborrheic dermatitis,
allergic dermatitis, atopic dermatitis, and psoriasis.

Invasive (granulomatous/necrotizing/malignant) otitis externa: necrosis of adjacent cartilage or bone of the


external auditory canal.

Others (keratosis obturans): hyperkeratosis of the external auditory canal skin, leading to corrosion of the
canal bone.

Bacterial versus fungal


Bacterial is more common than fungal. The most common pathogens are Pseudomonas aeruginosa and
Staphylococcus aureus . Fungal otitis externa is most commonly caused by Aspergillus .

Malignant or necrotizing
Occurs when the infection and inflammatory process involve not only the skin and soft tissue of the external
auditory canal but the bone tissue of the temporal bone as well.

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Otitis externa Prevention

Primary prevention
Primary prevention of AOE is aimed at avoidance of risk factors. Prevention mainly centers on the
preservation of the natural defense mechanism of the external auditory canal, which includes skin integrity.[1]
This can be achieved by avoidance of water accumulation and retention in the ear canal.[1] Factors that
might cause water retention include blockage of the external ear canal by wax or a foreign body, prolonged
use of hearing protector devices, and swimming. There are no available randomized trials to assess
efficacy of different strategies in prevention, but recommendations have been made in the literature.[1]
These include removal of obstructing cerumen,[11] water precautions, the use of acidifying ear drops after
swimming, and avoidance of trauma to the ear canal from cotton-tipped applicators and other objects. Other
suggested measures include treatment of underlying skin conditions such as dermatitis, diabetes control, and
avoidance of contact with certain products (neomycin drops, some types of ear molds) in patients with known
allergies.[1] [7]

Secondary prevention
Patients should be advised to avoid the use of foreign bodies in the ear. Patients with underlying skin
disorders should be treated. Patients who have wax accumulation or who have narrow ear canals should
PREVENTION

be followed up every 6 months to 1 year for wax cleaning. The use of acetic acid-containing ear drops after
swimming also helps patients with recurrent otitis externa in relation to swimming.[3]

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Otitis externa Diagnosis

Case history
Case history #1
A 35-year-old man presents with a 2-day history of rapid-onset severe ear pain and fullness. The patient
complains of otorrhea and mild decreased hearing. He reports that his symptoms started after swimming.
No fever is reported. On physical exam the external ear canal is diffusely swollen and erythematous.
He has tenderness of the tragus and pain with movement of the auricle. The tympanic membrane was
partially visualized due to the swelling. The concha and the pinna look normal. Neck exam fails to reveal
any lymphadenopathy.

Other presentations
Malignant or necrotizing otitis externa is a form of otitis externa that is more common in older patients with
uncontrolled diabetes or in patients with immunodeficiency.[1] [4] In malignant otitis externa, the infection
and the inflammatory process involve not only the skin and soft tissue of the external auditory canal but
the bone tissue of the temporal bone as well.[5] If left untreated, osteomyelitis of the petrous bone and/
or skull base could result.[5] [6] It is most commonly caused by Pseudomonas species.[1] [5] Patients
usually present with severe ear pain, otorrhea, and fullness, and are not responding to the conventional
treatment of AOE. Depending on the stage of presentation and the extent of invasion, patients may have
facial weakness and other cranial nerve abnormalities.[1] On physical exam the external auditory canal is
swollen, with evidence of granulation tissue in the floor of the canal.[1] The diagnosis is usually made by
CT or MRI scans, which show presence of soft tissue and bone destruction.[5] Technetium-99 or gallium
scans will show increased radioisotope uptake in the temporal bone and/or skull base.

Otomycosis is fungal otitis externa. Acute fungal otitis externa is less common than acute bacterial
otitis externa.[1] It is most commonly caused by Aspergillus species.[3] It presents in a similar way,
with ear pain, itching, aural fullness, and otorrhea. Physical exam reveals swollen ear canal skin and
discharge. The presence of black spores indicates Aspergillus niger as the causative organism.[1] [3]

DIAGNOSIS
White filamentous hyphae can often be seen. The definitive diagnosis of otomycosis can be helped by
microscopic examination and ear cultures. Otomycosis should be suspected in patients who fail treatment
with antibacterial agents.[3] Secondary fungal infection of the external auditory canal is well known after
prolonged treatment with topical antibacterial agents.

Step-by-step diagnostic approach


Diagnosis is usually clinical, with patients presenting with rapid onset of symptoms.[3]

History and physical exam


Patients usually present within 48 hours of the following symptoms: ear pain, itching, and fullness, with
or without decreased hearing.[1] On physical exam there may be tenderness over the tragus, pinna, or
both, and manipulation of the ear canal is usually painful. The skin of the external auditory canal has
variable degrees of diffuse edema, erythema, and swelling. Sometimes the canal is very swollen, and this
obscures the examination of the tympanic membrane. Variable amounts of drainage and debris will be
seen on otoscopic ear exam. In certain instances, cervical lymphadenopathy may be present.

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Otitis externa Diagnosis
[Fig-2]

Pneumatic otoscopy and/or tympanometry


Pneumatic otoscopy and tympanometry can be performed to aid in the diagnosis.[1] Pneumatic otoscopy
will demonstrate normal tympanic membrane movement, which may be absent in patients with associated
acute otitis media. Similarly, in AOE cases, tympanometry will be normal but will show flat tracing (type B)
in patients with associated acute otitis media. Tympanometry may cause discomfort and pain in patients
with AOE.

Culture and microscopy


Ear cultures are obtained mainly in patients who fail to improve with medical therapy. Cultures are
usually unnecessary on initial visit or at the time of diagnosis but can be obtained if desired.[3] The most
commonly cultured organisms are Pseudomonas and Staphylococcus species.[1] Negative cultures
are sometimes obtained in patients who are on antibiotic treatment, whether topical or systemic. Cultures
positive for fungal species are found in patients with fungal otitis externa.

Microscopy of exudate/debris from the ear canal may reveal evidence of fungal infection. White
filamentous hyphae are seen in cases of fungal otitis externa (otomycosis). The presence of black spores
indicates Aspergillus niger as the causative organism.[1] [3]

Radiology
CT scans of the temporal bone with and without contrast are usually obtained in patients who have severe
otalgia despite the initiation of medical therapy, or in the presence of granulation tissue in the ear canal,
to rule out malignant otitis externa.[1] In similar situations, and in cases where the CT scan shows bony
destruction, an MRI of the internal auditory canals and skull base is obtained to better delineate the extent
of infection. Patients with diabetes mellitus and other immunocompromised conditions are particularly
susceptible to necrotising/malignant otitis externa and require radiological evaluation if there is any
suspicion that they may have the condition.

Re-evaluation in patients refractory to treatment


DIAGNOSIS

Patients who fail to respond to conventional treatment of AOE should be re-evaluated to rule out fungal
otitis externa, necrotizing/malignant otitis externa, or, simply, noncompliance with treatment. Cultures
and microscopy can be obtained and may reveal filamentous hyphae and/or spores indicative of fungal
infection. Necrotizing otitis externa should be investigated in patients who fail to respond to medical
treatment and who have persistent ear pain despite maximal therapy. Radiologic evaluation with CT or
MR is indicated.

Risk factors
Strong
external auditory canal obstruction
• Obstruction of the external auditory canal by cerumen may promote retention of water and debris,
which, in turn, may disrupt the integrity of the skin of the external auditory canal.[7] This in itself, or in
the presence of additional risk factors, can cause infection. External auditory canal obstruction can be
caused by foreign bodies, a narrow ear canal, or bony exostosis.

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Otitis externa Diagnosis
high environmental humidity
• More common in areas with warmer weather or high humidity, or with increased water exposure from
swimming.[1] This in itself may be enough to affect skin integrity and cause infection.[3]

warmer environmental temperatures


• More common in areas with warmer weather or high humidity, or with increased water exposure from
swimming.[1] This in itself may be enough to affect skin integrity and cause infection.[3]

swimming
• More common in areas with warmer weather or high humidity, or with increased water exposure from
swimming.[1] This in itself may be enough to affect skin integrity and cause infection.[3]

local trauma
• Trauma disrupts the integrity of the external auditory canal skin and will initiate the process of
inflammation.[3] [10] Local trauma can result from manual wax cleaning, use of irrigation to clean wax,
and the use of foreign objects in the ear such as cotton-tipped applicators.

allergy
• Most commonly from antibiotic ear drops such as neomycin.[2]

skin disease
• Includes allergic dermatitis, atopic dermatitis, and psoriasis.[2]

diabetes
• Patients with diabetes, those who have received irradiation, or those who are immunocompromised
are at higher risk for severe cases of otitis externa, and this fact can modify the management of those
patients.[1] [7] 1[C]Evidence

immunocompromised
• Patients with diabetes, those who have received irradiation, or those who are immunocompromised

DIAGNOSIS
are at higher risk for severe cases of otitis externa, and this fact can modify the management of those
patients.[1] [7] 2[C]Evidence

prolonged used of topical antibacterial agents


• These agents may inhibit the normal flora after prolonged use on the external auditory canal, and their
use is a risk factor for fungal otitis externa.

Weak
chemical irritants
• Chemicals contained in ear medications, ear plugs, shampoo, and hair products can irritate and
inflame the skin of the ear and make it susceptible to infection.

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Otitis externa Diagnosis

History & examination factors


Key diagnostic factors
ear pain (common)
• Patients with AOE typically present with an acute onset of ear pain.[1]

tragal tenderness (common)


• The patient will usually complain of tenderness with manipulation of the tragus.[1]

ear canal swelling and erythema (common)


• On physical exam the skin of the external auditory canal appears erythematous and swollen.[1]

granulation tissue in the ear canal (malignant otitis externa) (uncommon)


• A key factor in malignant otitis externa cases.[1]

Other diagnostic factors


otorrhea (common)
• Discharge from the external auditory canal may be present in cases of acute otitis externa.[1]

aural fullness (common)


• Patients may complain of a fullness in the ears.[1]

itching (common)
• Patients may complain of itchiness in the ears.[1] Scratching with matchsticks or cotton buds often
precedes infection.

decreased hearing (common)


• In the absence of concomitant acute otitis media, hearing loss is usually secondary to blockage of the
DIAGNOSIS

ear canal by swelling and/or debris.[1]

erythematous tympanic membrane (common)


• In addition to swelling in the external auditory canal, the tympanic membrane may appear
erythematous,[1] which can make exclusion and differentiation from acute otitis media difficult.

Diagnostic tests
1st test to order

Test Result
pneumatic otoscopy normal
• Normal in patients with AOE alone, but abnormal in patients with
otitis media alone or in combination with AOE.

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Otitis externa Diagnosis

Test Result
tympanometry normal
• Normal in patients with AOE alone, but abnormal in patients with
otitis media alone or in combination with AOE. May cause discomfort
in patients with AOE.

Other tests to consider

Test Result
ear culture growth of the causative
pathogen
• Ear cultures are recommended in patients who fail to respond to
conventional therapy, and results will direct the choice of systemic
antibiotics.[3]
microscopy of exudate/debris from ear canal white filamentous hyphae
and/or black spores in
• White filamentous hyphae are seen on microscopic examination
otomycosis
of exudate/debris from the ear canal in cases of fungal otitis
externa (otomycosis).The presence of black spores indicates
Aspergillus niger as the causative organism in fungal otitis externa
(otomycosis).[1] [3]
CT scan of the temporal bone with IV contrast bony erosion and invasion
of petrous apex or skull
• CT scans are recommended in patients who have persistent severe
base
ear pain and fullness despite adequate medical therapy with topical
and oral antibiotics. This is to rule out malignant otitis externa. Clinical
features that would suggest a need for a CT scan include pain that is
disproportionate to the clinical findings and patients with granulation
tissue along the floor of the external auditory canal, especially in
diabetic or immunocompromised patients.[1]
MRI of the brain and internal auditory canals (with and without soft tissue outside the
gadolinium) confines of the external
auditory canal
• Ordered in addition to CT scan when malignant or necrotizing otitis

DIAGNOSIS
externa is suspected, especially in diabetic or immunocompromised
patients.

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Otitis externa Diagnosis

Differential diagnosis

Condition Differentiating signs / Differentiating tests


symptoms
Acute otitis media • Acute otitis media and • Tympanometry will reveal a
AOE present with ear pain. normal peaked curve in AOE
Hearing loss may be present but a flat (type B) curve in
in both. Tympanic membrane acute otitis media.[1]
may be erythematous
in AOE, making it more
challenging to rule out
either an associated acute
otitis media or acute otitis
media alone. Pneumatic
otoscopy shows mobility of
the tympanic membrane in
AOE and limited or absent
mobility in acute otitis
media.[1]

Furunculosis • Furunculosis is sometimes • No differentiating tests.


referred to as localized
AOE.[1] It usually represents
a localized infected hair
follicle in the cartilaginous
portion of the ear canal.[12]
The presenting symptoms
are similar to those of diffuse
AOE. It presents with otalgia
and tenderness.
• On physical exam the
infection is confined to
the cartilaginous portion
of the ear canal.[3] The
DIAGNOSIS

bony (medial) portion of the


external auditory canal is
usually normal.

Contact dermatitis of the • This is an allergic reaction • No differentiating tests.


ear canal to antigens that could be
present in hearing aid
material, cosmetics, and
other topical otic solutions.
Patients usually give history
of prior use of topical
solutions.
• Among the topical solutions,
neomycin is the most
commonly implicated
agent.[1] Patients with
allergies to otic topical
solutions usually present
with erythema and edema
that extend into the conchal
bowl.

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Otitis externa Diagnosis

Condition Differentiating signs / Differentiating tests


symptoms
Viral infections of the • Severe otalgia, facial • No differentiating tests.
external ear paralysis or paresis, taste
disturbance on the anterior
two-thirds of the tongue, and
decreased lacrimation on
the affected side.[1] Physical
exam may reveal erythema
and/or vesicles in the ear
canal and auricle.[3]

Chronic otitis externa • Chronic otitis externa is • No differentiating tests.


inflammation of the ear canal
skin. It usually presents with
diffuse low-grade infection of
months' or, at times, years'
duration.[10] It is the result
of recurrent otitis externa,
bacterial or fungal infections,
underlying skin conditions,
or otorrhea from middle
ear infections.[3] Patients
usually present with itching
and scant otorrhea but no
pain.[10]
• Physical examination of the
ear varies, depending on the
severity of the infection, and
can range from dry skin to
granulation tissue.[10]

Cancer of the external • Recalcitrant to usual medical • Biopsy of the external


auditory canal therapy. auditory canal.[1]

DIAGNOSIS
Cholesteatoma • Consider particularly in • CT can help with confirming
recalcitrant cases not the diagnosis, assessing
responding to medical disease extension, and
therapy. Otoscopy typically treatment planning.
shows crust or keratin in
the attic (upper part of
the middle ear), the pars
flaccida, or the pars tensa
(usually posterior superior
aspect), with or without a
perforation of the tympanic
membrane.

Ear canal cholesteatoma • Rare disease of the external • CT may reveal a localized
auditory canal. It usually cholesteatoma, with or
presents with ear discharge, without extension into the
focal erosion, and keratin middle ear or mastoid cavity.
accumulation in the bony ear
canal.[13]

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Otitis externa Treatment

Step-by-step treatment approach


The main goals of treatment are to control pain, cure infection, and prevent recurrence. Treatment is usually
given as for bacterial infection initially. Treatment for fungal infection is given if there are visual signs of fungal
growth, or if presumptive bacterial treatment has failed. Prior to the use of topical ear drops, the ear canal
needs to be cleaned of any debris or wax. This allows the status of the tympanic membrane to be checked
as well as enhancing skin penetration of the topical solution.[7] When applying ear drops, the patient should
be advised to apply the drops lying down with the affected ear upward and wait for 5 to 10 minutes before
getting up.

Bacterial
Several ear drops are available for first-line treatment. Studies have failed to demonstrate difference in
outcome with different products.[1] [14] The choice of the ear drop should be based on patient preference,
with the clinician's experience taking into account efficacy, low incidence of adverse events, likelihood of
adherence to therapy, and cost.[1] One of the early treatments consisted of topical acetic acid, and a 2007
study confirmed trichloroacetic acid as an effective and safe treatment for acute otitis externa.[15]

Currently, topical antibiotic solutions are more commonly used in AOE.[16] 3[A]Evidence Neomycin- and
polymyxin B-containing solutions were one of the first antibiotic ear drops to be used and demonstrated
efficacy against pathogens causing AOE.4[B]Evidence In one randomized controlled study, polymyxin B/
neomycin/gramicidin was found to be superior to glycerol ear drops.[19] The addition of dexamethasone
to such preparations was found to hasten symptomatic relief.[20] However, solutions containing neomycin
or polymixin-B are to be avoided in patients with tympanic membrane perforation due to potential
ototoxicity.[1] [16]

Fluoroquinolone-containing (ciprofloxacin and ofloxacin) agents have become available and are effective
against both the gram-negative and gram-positive pathogens that are common in otitis externa.[16]
5[B]Evidence 6[A]Evidence In a systematic review of the literature, it was found that a combined
ciprofloxacin/dexamethasone preparation is safe and effective in patients with acute otitis externa.[23]
One meta-analysis found that quinolone-containing ear drops are superior to combination drugs not
containing a quinolone.[24] Hypersensitivity to fluoroquinolone ear drops is not very common, and
they can be used in patients with tympanic membrane perforations.[1] [16] The usual dose of the
fluoroquinolone-containing ear drops is twice daily, compared with the older solutions where usage
is three times daily, which might have a favorable effect on compliance. In a randomized clinical
study of patients with acute otitis externa, it was found that a combined ciprofloxacin/dexamethasone
preparation resulted in less time to cure when compared with polymyxin B/neomycin/hydrocortisone
otic suspension.[25] Another randomized clinical trial found ciprofloxacin/dexamethasone otic to be
equal in effectiveness to topical neomycin/polymyxin B/hydrocortisone administered with systemic
amoxicillin in the treatment of acute otitis externa.[26] These observations have produced a shift in
treatment preference toward the newer fluoroquinolone-containing ear drops.[16] However, the older
topical solutions are still very commonly used and their cost is lower, making them more affordable.

A new quinolone, finafloxacin, is now FDA approved for topical use for treatment of acute otitis externa
TREATMENT

caused by susceptible strains of Pseudomonas aeruginosa and Staphylococcus aureus .

Care should be exercised in patients who are known, or suspected, to have a tympanic membrane
perforation to avoid ototoxic ear drops (those that contain aminoglycosides and alcohol).[1] In that
situation, ofloxacin or ciprofloxacin/dexamethasone can be used.[1]

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Otitis externa Treatment
For patients who fail to show response to initial ear drop treatment within 48 to 72 hours, culture of the
external auditory canal and additional cleaning of the ear canal from debris are recommended. Unless
there is evidence of fungal infection, such patients benefit from the addition of oral antibiotics. Culture and
sensitivity may help to guide antibiotic therapy in refractory cases.

Patients with other medical problems


Patients with diabetes, those who have received irradiation, or those who are immunocompromised
are at higher risk for rapid escalation from mild to severe manifestation or for developing malignant
otitis externa.[7] [27] Treatment approach in these patients is different and requires the use of systemic
antibiotics in addition to the treatment outlined under the general approach above.[1] [10] Oral
ciprofloxacin is an effective medication; however, it cannot be used in children.[10] In these patients,
cultures may be taken to assist in the proper choice of oral antibiotics.

For patients who fail to show response to initial ear drop treatment, culture of the external auditory canal
and additional cleaning of the ear canal from debris are recommended. Culture and sensitivity may help
to guide alternative antibiotic therapy in refractory cases.

Malignant or necrotizing otitis externa


All patients in this group should have debridement of granulation tissue. Patients can be given oral
ciprofloxacin for 6 to 8 weeks.[28] Oral ciprofloxacin has good coverage against Pseudomonas and
is very commonly and successfully used in these patients. Oral fluoroquinolones are active against
Pseudomonas aeruginosa , penetrate bone well, have excellent oral bioavailability, and have a less
significant side effect profile compared with alternatives.[29] If patients have failed to respond to
ciprofloxacin, they should be started on intravenous antibiotics that have antipseudomonas activity
until culture and sensitivity results are obtained. Empirical IV antibiotics should be started based on the
recommendation of the local infectious disease specialist. There is no standard recommendation, and
the literature reports use of a wide range of antibiotics both singularly and in combination, including third-
and fourth-generation cephalosporins (ceftazidime, cefepime), semi-synthetic penicillins (piperacillin),
carbapenems (imipenem), aztreonam, and aminoglycosides (amikacin, tobramycin).[30] [31] In the
absence of specialist infectious disease advice, the author considers ceftazidime a reasonable first
choice, with the others as alternative options. Hyperbaric oxygenation can be used in refractory or
recurrent cases, or in patients with extensive skull base or intracranial involvement.[30] A systematic
review about the use of hyperbaric oxygen as an adjuvant treatment for malignant otitis externa failed
to show clear evidence demonstrating its efficacy when compared with treatment with antibiotics and/or
surgery.[32]

Fungal
The first line of treatment of fungal otitis externa is still in debate.[3] However, the use of acidifying
agents is effective in most cases.[33] Patients who fail treatment with acidifying agents can be started
on antifungal topical treatment.[33] If Candida is cultured, an oral antifungal (e.g., fluconazole,
itraconazole) may help.[10] [34] Further studies are needed to assess the benefit of oral antifungal agents
in otomycosis.[34] Repeated ear cleaning is also an essential part of treatment. In patients with tympanic
TREATMENT

membrane perforation, tolnaftate should be used to prevent ototoxicity.[33] AOE secondary to Aspergillus
infections may require the use of oral itraconazole.[33] If fungal otitis externa is refractory to treatment and
there is progression of disease, consider fungal malignant otitis externa.[35]

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BMJ Best Practice topics are regularly updated and the most recent version
15
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment
Severe swelling of the ear canal
Patients who have severe swelling of the ear canal may have difficulty applying the ear drops. A
wick should be inserted in the ear canal to allow for drug delivery. Such wicks are often made of
dry, compressed Merocel® in a form that facilitates insertion into the swollen ear canal. Subsequent
application of topical antibiotic solution expands the wick to fill the canal and make contact with the
swollen tissue, thus enhancing penetration of the medication to the inflamed tissue. The wick can then
either be removed or replaced after 48 hours if swelling persists.

Analgesics
Analgesics increase patient satisfaction and allow faster return to normal activities. Mild to moderate
pain is usually controlled by acetaminophen or a nonsteroidal anti-inflammatory drug given alone or in
combination with an opioid (e.g., acetaminophen with codeine, oxycodone, or hydrocodone; or ibuprofen
with oxycodone).[1] Codeine is contraindicated in children younger than 12 years of age, and it is not
recommended in adolescents 12 to 18 years of age who are obese or have conditions such as obstructive
sleep apnea or severe lung disease as it may increase the risk of breathing problems.[36] It is generally
recommended only for the treatment of acute moderate pain, which cannot be successfully managed with
other analgesics, in children 12 years of age and older. It should be used at the lowest effective dose for
the shortest period and treatment limited to 3 days.[37] [38]

Treatment details overview


Consult your local pharmaceutical database for comprehensive drug information including contraindications,
drug interactions, and alternative dosing. ( see Disclaimer )

Acute ( summary )
Patient group Tx line Treatment

initial treatment in 1st antibacterial otic drops


otherwise healthy people

initial treatment in adjunct pain management


otherwise healthy people

refractory to initial 1st topical and systemic antibacterial therapy


treatment, or diabetic or
immunocompromised

refractory to initial adjunct pain management


treatment, or diabetic or
immunocompromised

malignant or necrotizing 1st topical and systemic antibacterial therapy


plus debridement

malignant or necrotizing adjunct hyperbaric ox ygen


TREATMENT

malignant or necrotizing adjunct pain management

malignant or necrotizing 2nd intravenous antibiotic therapy plus


debridement

malignant or necrotizing adjunct hyperbaric ox ygen

16 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Acute ( summary )
malignant or necrotizing adjunct pain management

initial treatment, 1st topical or oral treatment


nonperforated tympanic
membrane

initial treatment, adjunct pain management


nonperforated tympanic
membrane

perforated tympanic 1st tolnaftate otic drops


membrane

perforated tympanic adjunct pain management


membrane

TREATMENT

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
17
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Treatment options

Acute
Patient group Tx line Treatment

initial treatment in 1st antibacterial otic drops


otherwise healthy people
» Initial treatment refers to otherwise healthy
people without any extension to the outside ear
canal.

» Prior to the use of topical ear drops, the ear


canal needs to be cleaned of any debris or wax.

» Patients who have severe swelling of the ear


canal may have difficulty applying ear drops. A
wick should be inserted in the ear canal to allow
for drug delivery.

» Ciprofloxacin/dexamethasone and ofloxacin


can be used in patients with perforated tympanic
membranes.

» Ototoxic ear drops (those that contain


aminoglycosides and alcohol) should be avoided
in patients with possible tympanic perforations.
[1]

Primary options

» ciprofloxacin/dexamethasone otic:
(0.3%/0.1%) children ≥6 months of age and
adults: 4 drops into the affected ear(s) twice
daily for 7-10 days

OR
Primary options

» ofloxacin otic: (0.3%) children ≥6 months


of age: 5 drops into the affected ear(s) once
daily for 7 days; adults: 10 drops into the
affected ear(s) once daily for 7 days

OR
Primary options

» finafloxacin otic: (0.3%) children and adults:


4 drops into the affected ear(s) twice daily for
7 days
For patients requiring use of an otowick,
TREATMENT

the initial dose can be doubled to 8 drops,


followed by 4 drops twice daily.

OR
Secondary options

18 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Acute
Patient group Tx line Treatment
» ciprofloxacin/hydrocortisone otic: (0.2%/1%)
children ≥1 year of age and adults: 3 drops
into the affected ear(s) twice daily for 7-10
days

OR
Secondary options

» neomycin/polymyxin B/gramicidin
ophthalmic: children and adults: 1-2 drops
into the affected eye(s) four to six times daily
for 7-10 days

OR
Secondary options

» neomycin/polymyxin B/hydrocortisone otic:


children: 3 drops into the affected ear(s) three
to four times daily for 7-10 days; adults: 4
drops into the affected ear(s) three to times
daily for 7-10 days

OR
Secondary options

» acetic acid otic: (2%) children and adults:


3-5 drops into the affected ear(s) three times
daily for 7-10 days

OR
Secondary options

» hydrocortisone/acetic acid otic: (1%/2%)


children ≥3 years of age and adults: 3-5
drops into the affected ear(s) three times
daily for 7-10 days
initial treatment in adjunct pain management
otherwise healthy people
» Initial treatment refers to otherwise healthy
people without any extension to the outside ear
canal.

» Analgesics increase patient satisfaction and


allow faster return to normal activities.

» Mild to moderate pain is usually controlled


by acetaminophen or a nonsteroidal
anti-inflammatory drug given alone or in
TREATMENT

combination with an opioid (acetaminophen with


codeine, acetaminophen with oxycodone, or
acetaminophen with hydrocodone, or ibuprofen
with oxycodone).[1] Analgesics should be started
at the initial recommended dose and adjusted
accordingly.

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
19
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Acute
Patient group Tx line Treatment
» Codeine is contraindicated in children younger
than 12 years of age, and it is not recommended
in adolescents 12 to 18 years of age who are
obese or have conditions such as obstructive
sleep apnea or severe lung disease as it may
increase the risk of breathing problems.[36] It is
generally recommended only for the treatment
of acute moderate pain, which cannot be
successfully managed with other analgesics, in
children 12 years of age and older. It should be
used at the lowest effective dose for the shortest
period and treatment limited to 3 days.[37] [38]

Primary options

» acetaminophen: children: 10-15 mg/kg


orally/rectally every 4-6 hours when required,
maximum 75 mg/kg/day; adults: 325-1000
mg orally every 4-6 hours when required,
maximum 4000 mg/day

OR
Primary options

» ibuprofen: children: 5-10 mg/kg orally every


6-8 hours when required, maximum 40 mg/
kg/day; adults: 200-400 mg orally every 4-6
hours when required, maximum 2400 mg/day

OR
Secondary options

» acetaminophen/codeine: children ≥12 years


of age: consult specialist for guidance on
dose; adults: 15-60 mg orally orally every 4-6
hours
Adults: dose refers to codeine component.
Maximum dose is based on acetaminophen
component of 4000 mg/day.

OR
Secondary options

» oxycodone/acetaminophen: adults: 5-10 mg


orally (immediate-release) every 4-6 hours
when required
Adults: dose refers to oxycodone component.
Maximum dose is based on acetaminophen
TREATMENT

component of 4000 mg/day.

OR
Secondary options

20 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Acute
Patient group Tx line Treatment
» hydrocodone/acetaminophen: adults: 5-10
mg orally (immediate-release) every 4-6
hours when required
Adults: dose refers to hydrocodone
component. Maximum dose is based on
acetaminophen component of 4000 mg/day.

OR
Secondary options

» oxycodone/ibuprofen: adults: 5 mg/400 mg


(1 tablet) orally every 6 hours when required,
maximum 4 tablets/day
refractory to initial 1st topical and systemic antibacterial therapy
treatment, or diabetic or
» Patients who fail to respond to initial treatment
immunocompromised
or who are diabetic or immunocompromised
benefit from the addition of oral antibiotics.[1]

» Prior to the use of topical ear drops, the ear


canal needs to be cleaned of any debris or wax.

» Patients who have severe swelling of the ear


canal may have difficulty applying ear drops. A
wick should be inserted in the ear canal to allow
for drug delivery.

» Ciprofloxacin/dexamethasone and ofloxacin


can be used in patients with perforated tympanic
membranes and so are preferred in this
situation.

Primary options

» ciprofloxacin: children: consult specialist for


guidance on dose; adults: 500-750 mg orally
twice daily
--AND--
» ciprofloxacin/dexamethasone otic:
(0.3%/0.1%) children ≥6 months of age and
adults: 4 drops into the affected ear(s) twice
daily for 7-10 days
-or-
» ofloxacin otic: (0.3%) children ≥6 months
of age: 5 drops into the affected ear(s) once
daily for 7 days; adults: 10 drops into the
affected ear(s) once daily for 7 days
refractory to initial adjunct pain management
TREATMENT

treatment, or diabetic or
» Analgesics increase patient satisfaction and
immunocompromised
allow faster return to normal activities.

» Mild to moderate pain is usually controlled


by acetaminophen or a nonsteroidal
anti-inflammatory drug given alone or in

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
21
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Acute
Patient group Tx line Treatment
combination with an opioid (acetaminophen with
codeine, acetaminophen with oxycodone, or
acetaminophen with hydrocodone, or ibuprofen
with oxycodone).[1] Analgesics should be started
at the initial recommended dose and adjusted
accordingly.

» Codeine is contraindicated in children younger


than 12 years of age, and it is not recommended
in adolescents 12 to 18 years of age who are
obese or have conditions such as obstructive
sleep apnea or severe lung disease as it may
increase the risk of breathing problems.[36] It is
generally recommended only for the treatment
of acute moderate pain, which cannot be
successfully managed with other analgesics, in
children 12 years of age and older. It should be
used at the lowest effective dose for the shortest
period and treatment limited to 3 days.[37] [38]

Primary options

» acetaminophen: children: 10-15 mg/kg


orally/rectally every 4-6 hours when required,
maximum 75 mg/kg/day; adults: 325-1000
mg orally every 4-6 hours when required,
maximum 4000 mg/day

OR
Primary options

» ibuprofen: children: 5-10 mg/kg orally every


6-8 hours when required, maximum 40 mg/
kg/day; adults: 200-400 mg orally every 4-6
hours when required, maximum 2400 mg/day

OR
Secondary options

» acetaminophen/codeine: children ≥12 years


of age: consult specialist for guidance on
dose; adults: 15-60 mg orally orally every 4-6
hours
Adults: dose refers to codeine component.
Maximum dose is based on acetaminophen
component of 4000 mg/day.

OR
TREATMENT

Secondary options

» oxycodone/acetaminophen: adults: 5-10 mg


orally (immediate-release) every 4-6 hours
when required

22 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Acute
Patient group Tx line Treatment
Adults: dose refers to oxycodone component.
Maximum dose is based on acetaminophen
component of 4000 mg/day.

OR
Secondary options

» hydrocodone/acetaminophen: adults: 5-10


mg orally (immediate-release) every 4-6
hours when required
Adults: dose refers to hydrocodone
component. Maximum dose is based on
acetaminophen component of 4000 mg/day.

OR
Secondary options

» oxycodone/ibuprofen: adults: 5 mg/400 mg


(1 tablet) orally every 6 hours when required,
maximum 4 tablets/day
malignant or necrotizing 1st topical and systemic antibacterial therapy
plus debridement
» All patients in this group should have
debridement of granulation tissue.

» Oral fluoroquinolones are active against


Pseudomonas aeruginosa , penetrate bone well,
have excellent oral bioavailability, and have a
less significant side effect profile compared with
alternatives.[29]

» Topical ciprofloxacin/dexamethasone or
ofloxacin can be used in conjunction with
systemic ciprofloxacin and are safe to use in
patients with tympanic perforation.[1] Ototoxic
ear drops (those that contain aminoglycosides
and alcohol) should be avoided in patients with
possible tympanic perforations.[1]

Primary options

» ciprofloxacin: children: consult specialist for


guidance on dose; adults: 500-750 mg orally
twice daily for 6-8 weeks
--AND--
» ciprofloxacin/dexamethasone otic:
(0.3%/0.1%) children ≥6 months of age and
TREATMENT

adults: 4 drops into the affected ear(s) twice


daily for 7-10 days
-or-
» ofloxacin otic: (0.3%) children ≥6 months
of age: 5 drops into the affected ear(s) once

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
23
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Acute
Patient group Tx line Treatment
daily for 7 days; adults: 10 drops into the
affected ear(s) once daily for 7 days
--AND--
» debridement
malignant or necrotizing adjunct hyperbaric ox ygen
» Hyperbaric oxygenation can be used in
refractory or recurrent cases, or in patients
with extensive skull base or intracranial
involvement[30] although, in a systematic review,
no clear evidence was found in demonstrating
its efficacy when compared to treatment with
antibiotics and/or surgery.[32]

malignant or necrotizing adjunct pain management


» Analgesics increase patient satisfaction and
allow faster return to normal activities.

» Mild to moderate pain is usually controlled


by acetaminophen or a nonsteroidal
anti-inflammatory drug given alone or in
combination with an opioid (acetaminophen with
codeine, acetaminophen with oxycodone, or
acetaminophen with hydrocodone, or ibuprofen
with oxycodone).[1] Analgesics should be started
at the initial recommended dose and adjusted
accordingly.

» Codeine is contraindicated in children younger


than 12 years of age, and it is not recommended
in adolescents 12 to 18 years of age who are
obese or have conditions such as obstructive
sleep apnea or severe lung disease as it may
increase the risk of breathing problems.[36] It is
generally recommended only for the treatment
of acute moderate pain, which cannot be
successfully managed with other analgesics, in
children 12 years of age and older. It should be
used at the lowest effective dose for the shortest
period and treatment limited to 3 days.[37] [38]

Primary options

» acetaminophen: children: 10-15 mg/kg


orally/rectally every 4-6 hours when required,
maximum 75 mg/kg/day; adults: 325-1000
mg orally every 4-6 hours when required,
maximum 4000 mg/day
TREATMENT

OR
Primary options

» ibuprofen: children: 5-10 mg/kg orally every


6-8 hours when required, maximum 40 mg/

24 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Acute
Patient group Tx line Treatment
kg/day; adults: 200-400 mg orally every 4-6
hours when required, maximum 2400 mg/day

OR
Secondary options

» acetaminophen/codeine: children ≥12 years


of age: consult specialist for guidance on
dose; adults: 15-60 mg orally orally every 4-6
hours
Adults: dose refers to codeine component.
Maximum dose is based on acetaminophen
component of 4000 mg/day.

OR
Secondary options

» oxycodone/acetaminophen: adults: 5-10 mg


orally (immediate-release) every 4-6 hours
when required
Adults: dose refers to oxycodone component.
Maximum dose is based on acetaminophen
component of 4000 mg/day.

OR
Secondary options

» hydrocodone/acetaminophen: adults: 5-10


mg orally (immediate-release) every 4-6
hours when required
Adults: dose refers to hydrocodone
component. Maximum dose is based on
acetaminophen component of 4000 mg/day.

OR
Secondary options

» oxycodone/ibuprofen: adults: 5 mg/400 mg


(1 tablet) orally every 6 hours when required,
maximum 4 tablets/day
malignant or necrotizing 2nd intravenous antibiotic therapy plus
debridement
» All patients in this group should have
debridement of granulation tissue.

» If patients have failed to respond to


ciprofloxacin, they should be started
TREATMENT

on intravenous antibiotics that have


antipseudomonas activity until culture and
sensitivity results are obtained. Empirical
IV antibiotics should be started based on
the recommendation of the local infectious
disease specialist. There is no standard

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
25
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Acute
Patient group Tx line Treatment
recommendation, and the literature reports use
of a wide range of antibiotics both singularly
and in combination, including third- and fourth-
generation cephalosporins (ceftazidime,
cefepime), semi-synthetic penicillins
(piperacillin), carbapenems (imipenem/
cilastatin), aztreonam, and aminoglycosides
(amikacin, tobramycin).[30] [31] In the absence
of specialist infectious disease advice, the author
considers ceftazidime a reasonable first choice,
with the others as alternative options. Suggested
doses could vary depending on factors such
as the patient's renal function and severity of
infection. Amikacin and tobramycin have serious
potential side effects on renal function and
hearing and should be used with caution and
only after consultation with a infectious disease
specialist.

Primary options

» ceftazidime sodium: children: consult


specialist for guidance on dose; adults: 1 g
intravenoulsy every 8-12 hours, maximum 6
g/day

OR
Secondary options

» cefepime: 1-2 g intravenously every 12


hours

OR
Secondary options

» piperacillin: children: consult specialist for


guidance on dose; adults: 3-4 g intravenously
every 4-6 hours, maximum 24 g/day

OR
Secondary options

» imipenem/cilastatin: 500-750 mg
intravenously every 12 hours
Dose refers to imipenem component.

OR
Secondary options
TREATMENT

» aztreonam: 1-2 g intravenously every 8-12


hours

OR

26 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Acute
Patient group Tx line Treatment
Tertiary options

» amikacin: 7.5 mg/kg intravenously every 12


hours; or 5 mg/kg intravenously every 8 hours

OR
Tertiary options

» tobramycin: 3 mg/kg/day intravenously


given in divided doses every 8 hours
malignant or necrotizing adjunct hyperbaric ox ygen
» Hyperbaric oxygenation can be used in
refractory or recurrent cases, or in patients
with extensive skull base or intracranial
involvement[30] although, in a systematic review,
no clear evidence was found in demonstrating
its efficacy when compared to treatment with
antibiotics and/or surgery.[32]

malignant or necrotizing adjunct pain management


» Analgesics increase patient satisfaction and
allow faster return to normal activities.

» Mild to moderate pain is usually controlled


by acetaminophen or a nonsteroidal
anti-inflammatory drug given alone or in
combination with an opioid (acetaminophen with
codeine, acetaminophen with oxycodone, or
acetaminophen with hydrocodone, or ibuprofen
with oxycodone).[1] Analgesics should be started
at the initial recommended dose and adjusted
accordingly.

» Codeine is contraindicated in children younger


than 12 years of age, and it is not recommended
in adolescents 12 to 18 years of age who are
obese or have conditions such as obstructive
sleep apnea or severe lung disease as it may
increase the risk of breathing problems.[36] It is
generally recommended only for the treatment
of acute moderate pain, which cannot be
successfully managed with other analgesics, in
children 12 years of age and older. It should be
used at the lowest effective dose for the shortest
period and treatment limited to 3 days.[37] [38]

Primary options
TREATMENT

» acetaminophen: children: 10-15 mg/kg


orally/rectally every 4-6 hours when required,
maximum 75 mg/kg/day; adults: 325-1000
mg orally every 4-6 hours when required,
maximum 4000 mg/day

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
27
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Acute
Patient group Tx line Treatment
OR
Primary options

» ibuprofen: children: 5-10 mg/kg orally every


6-8 hours when required, maximum 40 mg/
kg/day; adults: 200-400 mg orally every 4-6
hours when required, maximum 2400 mg/day

OR
Secondary options

» acetaminophen/codeine: children ≥12 years


of age: consult specialist for guidance on
dose; adults: 15-60 mg orally orally every 4-6
hours
Adults: dose refers to codeine component.
Maximum dose is based on acetaminophen
component of 4000 mg/day.

OR
Secondary options

» oxycodone/acetaminophen: adults: 5-10 mg


orally (immediate-release) every 4-6 hours
when required
Adults: dose refers to oxycodone component.
Maximum dose is based on acetaminophen
component of 4000 mg/day.

OR
Secondary options

» hydrocodone/acetaminophen: adults: 5-10


mg orally (immediate-release) every 4-6
hours when required
Adults: dose refers to hydrocodone
component. Maximum dose is based on
acetaminophen component of 4000 mg/day.

OR
Secondary options

» oxycodone/ibuprofen: adults: 5 mg/400 mg


(1 tablet) orally every 6 hours when required,
maximum 4 tablets/day

initial treatment, 1st topical or oral treatment


TREATMENT

nonperforated tympanic
» Frequent cleaning by medical professionals is
membrane
necessary. Prior to the use of topical ear drops,
the ear canal needs to be cleaned of any debris
or wax.

28 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Acute
Patient group Tx line Treatment
» Patients who have severe swelling of the ear
canal may have difficulty applying ear drops. A
wick should be inserted in the ear canal to allow
for drug delivery.

» Oral antifungals may be used if caused by


candidal infection. Further studies are needed
to assess the benefit of oral antifungal agents in
otomycosis.[34] Dose and duration of treatment
for such an indication have not been fully
studied. Itraconazole may be used if caused by
Aspergillus infection.[33].

Primary options

» hydrocortisone/acetic acid otic: (1%/2%)


children ≥3 years of age and adults: 3-5
drops into the affected ear(s) three times
daily for 7-10 days

OR
Primary options

» acetic acid otic: (2%) children and adults:


3-5 drops into the affected ear(s) three times
daily for 7-10 days

OR
Secondary options

» clotrimazole topical: (1%) children ≥2 years


of age and adults: 3-4 drops into the affected
ear(s) three to four times daily for 7-10 days

OR
Tertiary options

» fluconazole: children and adults: consult


specialist for guidance on dose

OR
Tertiary options

» itraconazole: children and adults: consult


specialist for guidance on dose
initial treatment, adjunct pain management
nonperforated tympanic
» Analgesics increase patient satisfaction and
membrane
TREATMENT

allow faster return to normal activities.

» Mild to moderate pain is usually controlled


by acetaminophen or a nonsteroidal
anti-inflammatory drug given alone or in
combination with an opioid (acetaminophen with

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
29
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa Treatment

Acute
Patient group Tx line Treatment
codeine, acetaminophen with oxycodone, or
acetaminophen with hydrocodone, or ibuprofen
with oxycodone).[1] Analgesics should be started
at the initial recommended dose and adjusted
accordingly.

» Codeine is contraindicated in children younger


than 12 years of age, and it is not recommended
in adolescents 12 to 18 years of age who are
obese or have conditions such as obstructive
sleep apnea or severe lung disease as it may
increase the risk of breathing problems.[36] It is
generally recommended only for the treatment
of acute moderate pain, which cannot be
successfully managed with other analgesics, in
children 12 years of age and older. It should be
used at the lowest effective dose for the shortest
period and treatment limited to 3 days.[37] [38]

Primary options

» acetaminophen: children: 10-15 mg/kg


orally/rectally every 4-6 hours when required,
maximum 75 mg/kg/day; adults: 325-1000
mg orally every 4-6 hours when required,
maximum 4000 mg/day

OR
Primary options

» ibuprofen: children: 5-10 mg/kg orally every


6-8 hours when required, maximum 40 mg/
kg/day; adults: 200-400 mg orally every 4-6
hours when required, maximum 2400 mg/day

OR
Secondary options

» acetaminophen/codeine: children ≥12 years


of age: consult specialist for guidance on
dose; adults: 15-60 mg orally orally every 4-6
hours
Adults: dose refers to codeine component.
Maximum dose is based on acetaminophen
component of 4000 mg/day.

OR
Secondary options
TREATMENT

» oxycodone/acetaminophen: adults: 5-10 mg


orally (immediate-release) every 4-6 hours
when required

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BMJ Best Practice topics are regularly updated and the most recent version
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Otitis externa Treatment

Acute
Patient group Tx line Treatment
Adults: dose refers to oxycodone component.
Maximum dose is based on acetaminophen
component of 4000 mg/day.

OR
Secondary options

» hydrocodone/acetaminophen: adults: 5-10


mg orally (immediate-release) every 4-6
hours when required
Adults: dose refers to hydrocodone
component. Maximum dose is based on
acetaminophen component of 4000 mg/day.

OR
Secondary options

» oxycodone/ibuprofen: adults: 5 mg/400 mg


(1 tablet) orally every 6 hours when required,
maximum 4 tablets/day
perforated tympanic 1st tolnaftate otic drops
membrane
» Frequent cleaning by medical professionals is
necessary. Prior to the use of topical ear drops,
the ear canal needs to be cleaned of any debris
or wax.

Primary options

» tolnaftate topical: (1%) children ≥2 years of


age and adults: 3-4 drops into the affected
ear(s) three to four times daily for 7 days
perforated tympanic adjunct pain management
membrane
» Analgesics increase patient satisfaction and
allow faster return to normal activities.

» Mild to moderate pain is usually controlled


by acetaminophen or a nonsteroidal
anti-inflammatory drug given alone or in
combination with an opioid (acetaminophen with
codeine, acetaminophen with oxycodone, or
acetaminophen with hydrocodone, or ibuprofen
with oxycodone).[1] Analgesics should be started
at the initial recommended dose and adjusted
accordingly.

» Codeine is contraindicated in children younger


than 12 years of age, and it is not recommended
TREATMENT

in adolescents 12 to 18 years of age who are


obese or have conditions such as obstructive
sleep apnea or severe lung disease as it may
increase the risk of breathing problems.[36] It is
generally recommended only for the treatment
of acute moderate pain, which cannot be

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Otitis externa Treatment

Acute
Patient group Tx line Treatment
successfully managed with other analgesics, in
children 12 years of age and older. It should be
used at the lowest effective dose for the shortest
period and treatment limited to 3 days.[37] [38]

Primary options

» acetaminophen: children: 10-15 mg/kg


orally/rectally every 4-6 hours when required,
maximum 75 mg/kg/day; adults: 325-1000
mg orally every 4-6 hours when required,
maximum 4000 mg/day

OR
Primary options

» ibuprofen: children: 5-10 mg/kg orally every


6-8 hours when required, maximum 40 mg/
kg/day; adults: 200-400 mg orally every 4-6
hours when required, maximum 2400 mg/day

OR
Secondary options

» acetaminophen/codeine: children ≥12 years


of age: consult specialist for guidance on
dose; adults: 15-60 mg orally orally every 4-6
hours
Adults: dose refers to codeine component.
Maximum dose is based on acetaminophen
component of 4000 mg/day.

OR
Secondary options

» oxycodone/acetaminophen: adults: 5-10 mg


orally (immediate-release) every 4-6 hours
when required
Adults: dose refers to oxycodone component.
Maximum dose is based on acetaminophen
component of 4000 mg/day.

OR
Secondary options

» hydrocodone/acetaminophen: adults: 5-10


mg orally (immediate-release) every 4-6
hours when required
TREATMENT

Adults: dose refers to hydrocodone


component. Maximum dose is based on
acetaminophen component of 4000 mg/day.

OR

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BMJ Best Practice topics are regularly updated and the most recent version
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Otitis externa Treatment

Acute
Patient group Tx line Treatment
Secondary options

» oxycodone/ibuprofen: adults: 5 mg/400 mg


(1 tablet) orally every 6 hours when required,
maximum 4 tablets/day

TREATMENT

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Otitis externa Follow up

Recommendations
Monitoring
FOLLOW UP

Patients do not usually require long-term monitoring. Patients who develop recurrent episodes should be
assessed for the presence of risk factors.

Patient instructions
During the acute phase of the treatment, patients should be instructed on how to use ear drops to ensure
adequate treatment. Patients should administer drugs into the affected ear while lying down and with the
affected ear facing upward. The patient should put in as many drops as necessary to fill the ear canal and
then massage the ear canal and pinna to help the drops reach the medial end of the canal. The patient is
asked to remain in that position for at least 5 minutes. Patients should avoid exposing the affected ear to
water during the acute phase of the treatment.

A search for predisposing factors is helpful and sometimes necessary for effective control and prevention
of recurrence. Patients should be educated to avoid the use of cotton-tipped applicators or other foreign
objects. Patients who report ear pain and infections after swimming should use occlusive ear plugs.
Underlying dermatitis or other skin disorders should be attended to and treated with topical corticosteroids
whenever needed. A search for possible allergy to certain ear drops and/or hearing aid components
should be alluded to. The need for careful blood sugar control should be stressed in diabetic patients.

Complications

Complications Timeframe Likelihood


contact dermatitis or other chemical-related swelling short term medium

This is secondary to a hypersensitivity reaction from the medication, most commonly neomycin. Cessation
of the offending ear drop and the use of other topical agents (such as ciprofloxacin/dexamethasone otic)
usually help.

cranial nerve palsy variable medium

Occurs mainly in association with malignant/necrotizing otitis externa. One case series found 40% (15/37)
of cases had facial nerve palsy and 24% (9/37) had multiple cranial nerve palsies.[39]

osteomyelitis of the skull base variable low

A complication of malignant/necrotizing otitis externa, which requires prolonged IV antibiotic treatment (for
months), tends to recur and has a significant mortality rate.

34 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
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Otitis externa Follow up

Prognosis

FOLLOW UP
Patients with uncomplicated diffuse otitis externa usually respond to treatment. Between 65% and 90% of
patients have clinical resolution within 7 to 10 days, regardless of agent used.[1]

The mortality rate of malignant otitis externa has decreased over the years from 50% to 0%-15%.[29] Facial
nerve paralysis is a poor prognostic factor, and its presence indicates the need for longer treatment.[29]
In such cases, recovery of the function of the facial nerve might not occur. Aspergillus infection and dural
enhancement of the middle cranial fossa and foramen magnum on MRI are other poor prognostic indicators
in patients with malignant otitis externa.[29]

Predisposing factors
A search for predisposing factors is helpful and sometimes necessary in patients with recurrent AOE.
Patients should be educated to avoid the use of cotton-tipped applicators or other foreign objects. Patients
who report ear pain and infections after swimming should use occlusive ear plugs. Underlying dermatitis or
other skin disorders should be attended to and treated with topical steroids whenever needed. A search for
possible allergy to certain ear drops and/or hearing aid components should be considered.

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BMJ Best Practice topics are regularly updated and the most recent version
35
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Otitis externa Guidelines

Treatment guidelines

North America

Clinical practice guideline: acute otitis externa 24491310 Rosenfeld RM,


Schwart z SR, Cannon CR, et al. American Academy of Otolaryngology-
Head and Neck Surgery Foundation. Clinical practice guideline: acute
otitis externa. Otolaryngol Head Neck Surg. 2014;150(suppl 1):S1-S24. ht tp://
oto.sagepub.com/content/150/1_suppl/S1.long
Published by: American Academy of Otolaryngology-Head and Neck Last published: 2014
Surgery Foundation
GUIDELINES

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Otitis externa Evidence scores

Evidence scores
1. Risk of severe otitis externa: there is poor-quality evidence from observational studies (case control
and cohort design) that patients with diabetes are at higher risk of developing severe otitis externa.[1]
Evidence level C: Poor quality observational (cohort) studies or methodologically flawed randomized
controlled trials (RCTs) of <200 participants.

2. Risk of severe otitis externa: there is poor-quality evidence from observational studies (case control
and cohort design) that patients who are immunocompromised are at higher risk of developing severe
otitis externa.[1]
Evidence level C: Poor quality observational (cohort) studies or methodologically flawed randomized
controlled trials (RCTs) of <200 participants.

3. Cure rates: there is good-quality evidence that topical antibacterials plus topical corticosteroids
increase cure rates at 21 days in people with diffuse acute otitis externa, compared with topical acetic
acid.[17]
Evidence level A: Systematic reviews (SRs) or randomized controlled trials (RCTs) of >200
participants.

4. Cure rates: there is medium-quality evidence that topical antibacterial polymyxin-neomycin-


hydrocortisone drops are equally effective as aluminum acetate drops at increasing cure rates at 4
weeks in people with acute diffuse otitis externa.[18]
Evidence level B: Randomized controlled trials (RCTs) of <200 participants, methodologically
flawed RCTs of >200 participants, methodologically flawed systematic reviews (SRs) or good quality
observational (cohort) studies.

5. Cure rates: there is medium-quality evidence that ciprofloxacin drops are equally effective as
polymyxin-neomycin-hydrocortisone drops at increasing cure rates at 14 to 28 days.[21]
Evidence level B: Randomized controlled trials (RCTs) of <200 participants, methodologically
flawed RCTs of >200 participants, methodologically flawed systematic reviews (SRs) or good quality
observational (cohort) studies.

6. Cure rates: there is good-quality evidence that ofloxacin drops are equally effective as hydrocortisone-
neomycin-polymyxin B drops at increasing cure rates at 10 days in people with diffuse otitis
externa.[22]
Evidence level A: Systematic reviews (SRs) or randomized controlled trials (RCTs) of >200
participants.
EVIDENCE SCORES

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of the topics can be found on bestpractice.bmj.com . Use of this content is
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Otitis externa References

Key articles
• Rosenfeld RM, Schwartz SR, Cannon CR, et al. American Academy of Otolaryngology-Head and
REFERENCES

Neck Surgery Foundation. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck
Surg. 2014;150(suppl 1):S1-S24. Full text Abstract

• Hirsch BE. Infections of the external ear. Am J Otolaryngol. 1992;13:145-155. Abstract

• Osguthorpe JD, Nielsen DR. Otitis externa: review and clinical update. Am Fam Physician.
2006;74:1510-1516. Full text Abstract

• Roland PS, Stroman DW. Microbiology of acute otitis externa. Laryngoscope. 2002;112:1166-1177.
Abstract

• Selesnick SH. Otitis externa: management of the recalcitrant case. Am J Otology. 1994;15:408-412.
Abstract

• Dohar JE. Evolution of management approaches for otitis externa. Pediatr Infect Dis J.
2003;22:299-308. Abstract

• Mösges R, Nematian-Samani M, Hellmich M, et al. A meta-analysis of the efficacy of quinolone


containing otics in comparison to antibiotic-steroid combination drugs in the local treatment of otitis
externa. Curr Med Res Opin. 2011;27:2053-2060. Full text Abstract

• Carfrae MJ, Kesser BW. Malignant otitis externa. Otolaryngol Clin North Am. 2008;41:537-549.
Abstract

• Sander R. Otitis externa: a practical guide to treatment and prevention. Am Fam Physician.
2001;63:927-936, 941-942. Full text Abstract

References
1. Rosenfeld RM, Schwartz SR, Cannon CR, et al. American Academy of Otolaryngology-Head and
Neck Surgery Foundation. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck
Surg. 2014;150(suppl 1):S1-S24. Full text Abstract

2. Browning GG. Aetiopathology of inflammatory conditions of the external and middle ear. In: Kerr AG,
ed. Scott Brown's otolaryngology. Oxford, UK: Butterworth-Heinemann; 1997.

3. Hirsch BE. Infections of the external ear. Am J Otolaryngol. 1992;13:145-155. Abstract

4. Lee SK, Lee SA, Seon SW, et al. Analysis of prognostic factors in malignant external otitis. Clin Exp
Otorhinolaryngol. 2017 Sep;10(3):228-35. Full text Abstract

5. Walshe P, Cleary M, McConn WR, et al. Malignant otitis externa: a high index of suspicion is still
needed for diagnosis. Irish Med J. 2002;95:14-16. Abstract

38 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa References
6. Johnson AK, Batra PS. Central skull base osteomyelitis: an emerging clinical entity. Laryngoscope.
2014 May;124(5):1083-7. Full text Abstract

REFERENCES
7. Osguthorpe JD, Nielsen DR. Otitis externa: review and clinical update. Am Fam Physician.
2006;74:1510-1516. Full text Abstract

8. Roland PS, Stroman DW. Microbiology of acute otitis externa. Laryngoscope. 2002;112:1166-1177.
Abstract

9. Rowlands S, Devalia H, Smith C, et al. Otitis externa in UK general practice: a survey using the UK
General Practice Research Database. Br J Gen Pract. 2001;51:533-538. Full text Abstract

10. Selesnick SH. Otitis externa: management of the recalcitrant case. Am J Otology. 1994;15:408-412.
Abstract

11. Schwartz SR, Magit AE, Rosenfeld RM, et al. Clinical practice guideline (update): earwax (cerumen
impaction). Otolaryngol Head Neck Surg. 2017 Jan;156(1_suppl):S1-29. Full text Abstract

12. Chan KL, Soo G, van Hasselt CA. Furunculosis. Ear Nose Throat J. 1997;76:126. Abstract

13. Dubach P, Mantokoudis G, Caversaccio M. Ear canal cholesteatoma: meta-analysis of clinical


characteristics with update on classification, staging and treatment. Curr Opin Otolaryngol Head Neck
Surg. 2010 Oct;18(5):369-76. Abstract

14. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database Syst Rev.
2010;(1):CD004740. Abstract

15. Kantas I, Balatsouras DG, Vafiadis M, et al. The use of trichloroacetic acid in the treatment of acute
external otitis. Eur Arch Otorhinolaryngol. 2007;264:9-14. Abstract

16. Dohar JE. Evolution of management approaches for otitis externa. Pediatr Infect Dis J.
2003;22:299-308. Abstract

17. van Balen FA, Smit WM, Zuithoff NP, et al. Clinical efficacy of three common treatments in acute otitis
externa in primary care: randomised controlled trial. BMJ. 2003;327:1201-1205. Full text Abstract

18. Lambert IJ. A comparison of the treatment of otitis externa with "Otosporin" and aluminium acetate: a
report from a services practice in Cyprus. J R Coll Gen Pract. 1981;31:291-294. Full text Abstract

19. Mösges R, Baues CM, Schröder T, et al. Acute bacterial otitis externa: efficacy and safety of topical
treatment with an antibiotic ear drop formulation in comparison to glycerol treatment. Curr Med Res
Opin. 2011;27:871-878. Full text Abstract

20. Mösges R, Schröder T, Baues CM, et al. Dexamethasone phosphate in antibiotic ear drops for the
treatment of acute bacterial otitis externa. Curr Med Res Opin. 2008;24:2339-2347. Abstract

21. Pistorius B, Westberry K, Drehobl M, et al. Prospective, randomized, comparative trial of ciprofloxacin
otic drops, with or without hydrocortisone, vs. polymyxin B-neomycin-hydrocortisone otic suspension in
the treatment of acute diffuse otitis externa. Infect Dis Clin Pract. 1999;8:387-395.

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
39
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa References
22. Jones RN, Milazzo J, Seidlin M. Ofloxacin otic solution for treatment of otitis externa in children and
adults. Arch Otolaryngol Head Neck Surg. 1997;123:1193-1200. Abstract
REFERENCES

23. Wall GM, Stroman DW, Roland PS, et al. Ciprofloxacin 0.3%/dexamethasone 0.1% sterile otic
suspension for the topical treatment of ear infections: a review of the literature. Pediatr Infect Dis J.
2009;28:141-144. Abstract

24. Mösges R, Nematian-Samani M, Hellmich M, et al. A meta-analysis of the efficacy of quinolone


containing otics in comparison to antibiotic-steroid combination drugs in the local treatment of otitis
externa. Curr Med Res Opin. 2011;27:2053-2060. Full text Abstract

25. Rahman A, Rizwan S, Waycaster C, et al. Pooled analysis of two clinical trials comparing the clinical
outcomes of topical ciprofloxacin/dexamethasone otic suspension and polymyxin B/neomycin/
hydrocortisone otic suspension for the treatment of acute otitis externa in adults and children. Clin
Ther. 2007;29:1950-1956. Abstract

26. Roland PS, Belcher BP, Bettis R, et al; Cipro HC Study Group. A single topical agent is clinically
equivalent to the combination of topical and oral antibiotic treatment for otitis externa. Am J
Otolaryngol. 2008;29:255-261. Abstract

27. Hannley MT, Denneny JC 3rd, Holzer SS. Use of ototopical antibiotics in treating 3 common ear
diseases. Otolaryngol Head Neck Surg. 2000;122:934-940. Abstract

28. Bernstein JM, Holland NJ, Porter GC, et al. Resistance of Pseudomonas to ciprofloxacin: implications
for the treatment of malignant otitis externa. J Laryngol Otol. 2007;121:118-123. Abstract

29. Carfrae MJ, Kesser BW. Malignant otitis externa. Otolaryngol Clin North Am. 2008;41:537-549.
Abstract

30. Sreepada GS, Kwartler JA. Skull base osteomyelitis secondary to malignant otitis externa. Curr Opin
Otolaryngol Head Neck Surg. 2003;11:316-323. Abstract

31. Franco-Vidal V, Blanchet H, Bebear C, et al. Necrotizing external otitis: a report of 46 cases. Otol
Neurotol. 2007;28:771-773. Abstract

32. Phillips JS, Jones SE. Hyperbaric oxygen as an adjuvant treatment for malignant otitis externa.
Cochrane Database Syst Rev. 2013;(5):CD004617. Full text Abstract

33. Sander R. Otitis externa: a practical guide to treatment and prevention. Am Fam Physician.
2001;63:927-936, 941-942. Full text Abstract

34. Martin TJ, Kerschner JE, Flanary VA. Fungal causes of otitis externa and tympanostomy tube otorrhea.
Int J Pediatr Otorhinolaryngol. 2005;69:1503-1508. Abstract

35. Mion M, Bovo R, Marchese-Ragona R, et al. Outcome predictors of treatment effectiveness for fungal
malignant external otitis: a systematic review. Acta Otorhinolaryngol Ital. 2015 Oct;35(5):307-13. Full
text Abstract

40 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Otitis externa References
36. US Food and Drug Administration. FDA drug safety communication: FDA restricts use of prescription
codeine pain and cough medicines and tramadol pain medicines in children; recommends against use
in breastfeeding women. April 2017. https://www.fda.gov/ (last accessed 21 April 2017). Full text

REFERENCES
37. Medicines and Healthcare Products Regulatory Agency. Codeine: restricted use as analgesic in
children and adolescents after European safety review. Drug Safety Update. 2013;6:S1. Full text

38. European Medicines Agency. Restrictions on use of codeine for pain relief in children - CMDh
endorses PRAC recommendation. June 2013. http://www.ema.europa.eu/ (last accessed 24 March
2016). Full text

39. Ali T, Meade K, Anari S, et al. Malignant otitis externa: case series. J Laryngol Otol.
2010;124:846-851. Abstract

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 30, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
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of the topics can be found on bestpractice.bmj.com . Use of this content is
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Otitis externa Images

Images
IMAGES

Figure 1: Diagram of acute otitis externa


Created by the BMJ Knowledge Centre

Figure 2: Swollen ear canal, almost completely closed due to acute otitis externa
From the collection of Dr Richard Buckingham

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Otitis externa Disclaimer

Disclaimer
This content is meant for medical professionals. The BMJ Publishing Group Ltd (“BMJ Group”) tries to
ensure that the information provided is accurate and uptodate, but we do not warrant that it is. The BMJ
Group does not advocate or endorse the use of any drug or therapy contained within nor does it diagnose
patients. Medical professionals should use their own professional judgement in using this information and
caring for their patients and the information herein should not be considered a substitute for that.

This information is not intended to cover all possible diagnosis methods, treatments, follow up, drugs and any
contraindications or side effects. We strongly recommend that users independently verify specified diagnosis,
treatments and follow up and ensure it is appropriate for your patient. This information is provided on an “as
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DISCLAIMER

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Contributors:

// Authors:

Soha Ghossaini, MD, FACS


Otology-Neurotology
Ear, Nose and Throat Associates of New York, Flushing, New York, NY
DISCLOSURES: SG declares that she has no competing interests.

// Peer Reviewers:

Peter S. Roland, MD
Professor Neurological Surgery
Chief of Pediatric Otology, Otolaryngology Head and Neck Surgery, UT Southwestern Medical Center,
Dallas, TX
DISCLOSURES: PSR has acted as a consultant to Alcon laboratories, makers of Ciprodex®, who
have provided compensation to the University of Texas Southwestern Medical Center Department of
Otolaryngology Head and Neck Surgery. PSR has received compensation for speaking and for organizing
educational events. PSR is co-author of the American Academy of Head and Neck Surgery's practice
guideline for AOE. PSR is an author of references cited in this monograph.

Anthony Wright, LLM, DM, FRCS


Emeritus Professor of Otolaryngology
UCL Ear Institute, London, UK
DISCLOSURES: AW declares that he has no competing interests.

Desmond A. Nunez, MD, FRCS(ORL)


Director ENT Unit
North Bristol NHS Trust, Honorary Reader in Otolaryngology, University of Bristol, Bristol, UK
DISCLOSURES: DAN declares that he has no competing interests.

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