12.1.1 Otitis externa

Otitis externa is inflammation, with or without infection, of the external ear canal. Many cases recover after thorough cleansing of the external ear canal by suction or dry mopping.

Caution is advised to ensure that the repeated episodes of irritation and discharge represent genuine otitis externa, and not an underlying chronic otitis media with perforation.

The most effective method is to introduce a ribbon gauze dressing soaked with corticosteroid ear drops or with an astringent such as aluminium acetate solution.

Ear swabs for culture should be reserved for treatment failures or chronic cases. They may be carried out using a urethral swab (i.e. narrow cotton-tipped swab on a wire, not a 'throat' swab).

Chronic or recurrent otitis externa

Some patients present with frequent otitis externa that may be related to water sports, vigorous ear cleaning or chronic dermatitis. For patients who develop itching, pain or irritation of the ear canals after exposure to water, an acetic acid (vinegar) and alcohol based ear wash can be very effective in avoiding development of infective and more severe otitis externa by immediate use after water has entered the ears.

Acetic acid 2%
  • Ear Calm® spray (£4.10 = 5ml)

Indications

  • Superficial infections of the external auditory canal

Dose

  • One spray every 8 hours for a maximum of 7 days

Notes

  1. Acetic acid 2% solution is antifungal and antibacterial and may be useful for mild otitis externa. The proprietary Ear Calm® spray may be obtained over the counter at pharmacies.

Anti-inflammatory preparations

Early brief treatment (as short as 48 hours) of exacerbations of chronic eczematous otitis externa with steroid ear drops may be helpful; however, avoid prolonged use of topical steroids. Microsuction should be considered where there is a build-up of debris or and inadequate response to initial topical treatment.

Betamethasone
  • Ear drops 0.1% (£2.32 = 10ml)

Indications

  • Eczematous inflammation in otitis externa

Dose

  • Apply 2–3 drops every 2–3 hours; reduce frequency when relief obtained

Notes

  1. Betamethasone products for use in nasal allergy please refer to 12.2 Nose
Prednisolone sodium phosphate
  • Ear drops 0.5% (£2.00 = 10ml)

Indications

  • Eczematous inflammation in otitis externa

Dose

  • Apply 2–3 drops every 2–3 hours; reduce frequency when relief obtained

Anti-infective preparations

Initial treatment of infective otitis externa is aural antibiotics and anti-inflammatory drops. There are no indications for systemic treatment unless systemic symptoms or local spread leading to oedema, cellulitis and erysipelas.

Consideration should be given to the fact that pseudomonal resistance to aminoglycoside antibiotics is growing.

In view of reports of ototoxicity in patients with a perforated tympanic membrane (eardrum), manufacturer's contra-indicate treatment with a topical aminoglycoside antibiotic in those with a tympanic perforation.

If infection is present a topical anti-infective agent that is not usually used systemically (e.g. neomycin or clioquinol) may be used, but for about a week as excessive use may result in fungal infections. Fungal infections are usually difficult to treat and specialist referral should be considered if this is suspected.

Anti-infective and anti-inflammatory combination products may be used for infections with inflammation/eczema. However, the combination products usually include an aminoglycoside so careful consideration should be made before prescribing these.

Fungal infection

Fungal external ear infections are not unusual and may be the result of over-use of aural and oral antibiotics. They may be difficult to treat; specialist referral should be considered if treatment with clotrimazole ear drops fails to resolve symptoms.

Clotrimazole
  • Solution 1% (£2.30 = 20ml)

Indications

  • Fungal infection in otitis externa

Dose

  • Apply 2–3 times daily continuing for at least 14 days after disappearance of infection
Clioquinol 1%, flumetasone 0.02%
  • Ear drops (£11.34 = 7.5ml)

Indications

  • Mild bacterial or fungal infections in otitis externa

Dose

  • Apply 2–3 drops into the ear every 12 hours for 7–10 days
Otomize®
  • Ear Spray: dexamethasone 0.1%, neomycin sulphate 3250 units/ml, glacial acetic acid 2% (£3.27 = 5ml)

Indications

  • Eczematous inflammation in otitis externa

Dose

  • Apply 1 metered spray 3 times daily
Gentisone HC®
  • Ear drops: hydrocortisone acetate 1%, gentamicin 0.3% (£4.76 = 10ml)

Indications

  • Bacterial infection in otitis externa

Dose

  • Apply 2–4 drops every 6-8 hours and at night for 7-10 days
Ciprofloxacin
  • Eye drops 0.3% (£4.70 = 5ml)

Indications

  • Acute otitis externa (unlicensed indication)
  • Acute otitis media (unlicensed indication)

Dose

  • Apply 2 drops three times a day for 10 days

Notes

  1. May be preferred in cases of tympanic perforation.
  2. These eye drops are not licensed for use in the ear but may be used when microbiologically appropriate.
  3. Eye drops should be prescribed over special obtain ear drop preparations due to significant difference in cost.
Gentamicin
  • Ear drop 0.3% (£2.47 = 10ml)

Indications

  • Bacterial infection in otitis externa

Dose

  • Apply 2–4 drops every 6-8 hours and at night for 7-10 days
Ceftazidime
  • Ear drops 5% (unlicensed preparation)
Sofradex®
  • Ear drops: dexamethasone 0.05%, framycetin sulphate 0.5%, gramicidin 0.005%

Notes

  1. Sofradex® is considered to be less suitable for prescribing as it contains an aminoglycosides (see BNF). This is linked to growing pseudomonal resistance. Sofradex® is reserved for use in hospital only where other preparations are not effective.
Kenacomb Otic
  • Ear ointment (triamcinolone acetonide with antibacterial) (unlicensed preparation)

 

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