Otitis externa medical therapy: Difference between revisions

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Latest revision as of 23:29, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Template:Chi; Maliha Shakil, M.D. [2]; Suveenkrishna Pothuru, M.B,B.S. [3]; Luke Rusowicz-Orazem, B.S.; Tarek Nafee, M.D. [4]

Overview

The mainstay of therapy for acute otitis externa (AOE) includes cleaning of the external auditory meatus and treating the infection. Topical therapy is recommended as the initial therapy for diffuse uncomplicated acute otitis externa. Systemic antimicrobials should be reserved for infections extending outside the external ear canal or patients with specific risk factors. Analgesics such as acetaminophen or nonsteroidal anti-inflammatory drugs are administered either alone or in combination with an opioid.

Medical Therapy

Topical therapy is recommended as initial therapy for diffuse uncomplicated AOE. A non-ototoxic topical preparation should be used when the patient has a known or suspected perforation of the tympanic membrane. Systemic antimicrobials may be administered if there is extension outside the external ear canal or in the presence of the following risk factors that would indicate a need for systemic therapy:^[1]

Diabetes
HIV infection or AIDS
Other immunocompromised states, such as patients with malignancies receiving chemotherapy
History of radiotherapy
Presence of tympanostomy tube or perforated tympanic membrane

Otitis externa

1. Otitis externa, acute ^[2]

1.1 Causative pathogens

Pseudomonas aeruginosa
Candida spp.
Enterobacteriaceae
Proteus spp.
Staphylococcus aureus

1.2 Empiric antimicrobial therapy

Preferred regimen (1): Acetic acid 2.0% TOP tid for 7-10 days
Preferred regimen (2): Acetic acid 2.0%, Hydrocortisone 1.0% TOP tid for 7-10 days
Preferred regimen (3): Ciprofloxacin 0.2%, Hydrocortisone 1.0% TOP tid for 7-10 days
Preferred regimen (4): Ciprofloxacin 0.3%, Dexamethasone 0.1% TOP tid for 7-10 days
Preferred regimen (5): Neomycin, Polymyxin B, Hydrocortisone TOP tid for 7-10 days
Preferred regimen (6): Ofloxacin 0.3% TOP tid for 7-10 days

1.3 Pathogen-directed therapy

1.3.1 Fungal otitis externa^[2]

Preferred regimen: Fluconazole 200 mg PO once THEN Fluconazole 100 mg PO q24h for 3–5 days

1.3.2 Malignant otitis media, Pseudomonas aeruginosa^[2]

Preferred regimen: Imipenem 0.5 g IV q6h OR Meropenem 1 g IV q8h OR Ciprofloxacin 400 mg IV q8h OR Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q12h OR (Piperacillin-Tazobactam 4-6g IV q4h AND Tobramycin 3–5 mg/kg/day IV q8h)
Note: Oral Ciprofloxacin may be used by only in patients with very early disease

2. Otitis externa, chronic^[2]

2.1 Empiric antimicrobial therapy

Preferred regimen: Neomycin, Polymyxin B, Hydrocortisone TOP q6-8h AND Selenium Sulfide Shampoo
Note: Selenium sulfide shampoo is recommended as the disease is usually secondary to seborrhea.

Pain Management

Analgesia should be administered based on the severity of pain. Mild to moderate pain is usually managed with acetaminophen or nonsteroidal anti-inflammatory drugs given alone or in combination with an opioid. Fentanyl, morphine, and hydromorphone are indicated for procedure-related and moderate to severe pain.

Algorithm for the Approach to Acute Otitis Externa

Abbreviations: AOE, acute otitis externa; TM, tympanic membrane. (Adapted from Clinical Practice Guideline: Acute Otitis Externa)^[3]

Diffuse AOE

Analgesic based on severity

Extension beyond ear canal or ⊕ factors requiring systemic Rx?

YES

NO

Abx against P. aeruginosa and S. aureus

Perforated TM?

YES

NO

Non-otoxic topical agent

Topical agent

Obstructed ear canal?

YES

NO

Aural toilet or wick placement

Educate pt on how to use ear drops

Clinically improve in 3 days?

YES

NO

Complete Rx course

Illness other than AOE?

YES

NO

Treat accordingly

Assess Rx adherence/delivery

References

↑ Rosenfeld, Richard M.; Schwartz, Seth R.; Cannon, C. Ron; Roland, Peter S.; Simon, Geoffrey R.; Kumar, Kaparaboyna Ashok; Huang, William W.; Haskell, Helen W.; Robertson, Peter J. (2014-02). "Clinical practice guideline: acute otitis externa". Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 150 (1 Suppl): –1-S24. doi:10.1177/0194599813517083. ISSN 1097-6817. PMID 24491310. Check date values in: |date= (help)
↑ ^2.0 ^2.1 ^2.2 ^2.3 Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA; et al. (2014). "Clinical practice guideline: acute otitis externa executive summary". Otolaryngol Head Neck Surg. 150 (2): 161–8. doi:10.1177/0194599813517659. PMID 24492208.
↑ Rosenfeld, Richard M.; Schwartz, Seth R.; Cannon, C. Ron; Roland, Peter S.; Simon, Geoffrey R.; Kumar, Kaparaboyna Ashok; Huang, William W.; Haskell, Helen W.; Robertson, Peter J. (2014-02). "Clinical practice guideline: acute otitis externa". Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 150 (1 Suppl): –1-S24. doi:10.1177/0194599813517083. ISSN 1097-6817. PMID 24491310. Check date values in: |date= (help)

Template:WH Template:WS

[1] Rosenfeld, Richard M.; Schwartz, Seth R.; Cannon, C. Ron; Roland, Peter S.; Simon, Geoffrey R.; Kumar, Kaparaboyna Ashok; Huang, William W.; Haskell, Helen W.; Robertson, Peter J. (2014-02). "Clinical practice guideline: acute otitis externa". Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 150 (1 Suppl): –1-S24. doi:10.1177/0194599813517083. ISSN 1097-6817. PMID 24491310. Check date values in: |date= (help)

[pmid24492208-2] 2.0 ^2.1 ^2.2 ^2.3 Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA; et al. (2014). "Clinical practice guideline: acute otitis externa executive summary". Otolaryngol Head Neck Surg. 150 (2): 161–8. doi:10.1177/0194599813517659. PMID 24492208.

[3] Rosenfeld, Richard M.; Schwartz, Seth R.; Cannon, C. Ron; Roland, Peter S.; Simon, Geoffrey R.; Kumar, Kaparaboyna Ashok; Huang, William W.; Haskell, Helen W.; Robertson, Peter J. (2014-02). "Clinical practice guideline: acute otitis externa". Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 150 (1 Suppl): –1-S24. doi:10.1177/0194599813517083. ISSN 1097-6817. PMID 24491310. Check date values in: |date= (help)

[1]

[2]

[3]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Otitis externa}}
-{{CMG}}
+{{CMG}}; {{AE}} {{Chi}}; {{Maliha}}; {{PSK}}; {{LRO}}; {{TarekNafee}}
 ==Overview==
-Management of otitis externa includes both cleaning the external canal and treating the infection.
+The mainstay of therapy for acute otitis externa (AOE) includes cleaning of the [[external auditory meatus]] and treating the infection. Topical therapy is recommended as the initial therapy for diffuse uncomplicated acute otitis externa.  Systemic antimicrobials should be reserved for infections extending outside the external ear canal or patients with specific risk factors. Analgesics such as [[acetaminophen]] or [[nonsteroidal anti-inflammatory drugs]] are administered either alone or in combination with an [[opioid]].
-==Antibiotic Therapy==
+==Medical Therapy==
-Topical preparations are recommended as initial therapy for diffuse, uncomplicated AOE.  Systemic antimicrobials may be administered if there is extension outside the external canal or the presence of the following host factors that would indicate a need for systemic therapy:<ref>{{Cite journal| doi = 10.1177/0194599813517083| issn = 1097-6817| volume = 150| issue = 1 Suppl| pages = –1-S24| last1 = Rosenfeld| first1 = Richard M.| last2 = Schwartz| first2 = Seth R.| last3 = Cannon| first3 = C. Ron| last4 = Roland| first4 = Peter S.| last5 = Simon| first5 = Geoffrey R.| last6 = Kumar| first6 = Kaparaboyna Ashok| last7 = Huang| first7 = William W.| last8 = Haskell| first8 = Helen W.| last9 = Robertson| first9 = Peter J.| title = Clinical practice guideline: acute otitis externa| journal = Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery| date = 2014-02| pmid = 24491310}}</ref>
+Topical therapy is recommended as initial therapy for diffuse uncomplicated AOE.  A non-ototoxic topical preparation should be used when the patient has a known or suspected perforation of the [[tympanic membrane]].  Systemic antimicrobials may be administered if there is extension outside the external ear canal or in the presence of the following risk factors that would indicate a need for systemic therapy:<ref>{{Cite journal| doi = 10.1177/0194599813517083| issn = 1097-6817| volume = 150| issue = 1 Suppl| pages = –1-S24| last1 = Rosenfeld| first1 = Richard M.| last2 = Schwartz| first2 = Seth R.| last3 = Cannon| first3 = C. Ron| last4 = Roland| first4 = Peter S.| last5 = Simon| first5 = Geoffrey R.| last6 = Kumar| first6 = Kaparaboyna Ashok| last7 = Huang| first7 = William W.| last8 = Haskell| first8 = Helen W.| last9 = Robertson| first9 = Peter J.| title = Clinical practice guideline: acute otitis externa| journal = Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery| date = 2014-02| pmid = 24491310}}</ref>
-* Diabetes
+* [[Diabetes]]
-* HIV infection or AIDS
+* [[HIV infection]] or [[AIDS]]
-* Other immunocompromised states, such as patients with malignancies receiving chemotherapy
+* Other [[immunocompromised]] states, such as patients with [[malignancies]] receiving [[chemotherapy]]
-* History of radiotherapy
+* History of [[radiotherapy]]
-* Presence of tympanostomy tubes or perforated tympanic membrane (nonintact tympanic membrane)
+* Presence of [[tympanostomy tube]] or perforated [[tympanic membrane]]
-===Acute Otitis Externa===
+===Otitis externa===
+*'''1. Otitis externa, acute''' <ref name="pmid24492208">{{cite journal| author=Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA et al.| title=Clinical practice guideline: acute otitis externa executive summary. | journal=Otolaryngol Head Neck Surg | year= 2014 | volume= 150 | issue= 2 | pages= 161-8 | pmid=24492208 | doi=10.1177/0194599813517659 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24492208  }} </ref>
+:*'''1.1 Causative pathogens'''
+::*Pseudomonas aeruginosa
+::*Candida spp.
+::*Enterobacteriaceae
+::*Proteus spp.
+::*Staphylococcus aureus
+:*'''1.2 Empiric antimicrobial therapy'''
+::*Preferred regimen (1): [[Acetic acid]] 2.0% TOP tid for 7-10 days
+::*Preferred regimen (2): [[Acetic acid]] 2.0%, [[Hydrocortisone]] 1.0% TOP tid for 7-10 days
+::*Preferred regimen (3): [[Ciprofloxacin]] 0.2%, [[Hydrocortisone]] 1.0% TOP tid for 7-10 days
+::*Preferred regimen (4): [[Ciprofloxacin]] 0.3%, [[Dexamethasone]] 0.1% TOP tid for 7-10 days
+::*Preferred regimen (5): [[Neomycin]], [[Polymyxin B]], [[Hydrocortisone]] TOP tid for 7-10 days
+::*Preferred regimen (6): [[Ofloxacin]] 0.3% TOP tid for 7-10 days
+:*'''1.3 Pathogen-directed therapy'''
+::*'''1.3.1 Fungal otitis externa'''<ref name="pmid24492208">{{cite journal| author=Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA et al.| title=Clinical practice guideline: acute otitis externa executive summary. | journal=Otolaryngol Head Neck Surg | year= 2014 | volume= 150 | issue= 2 | pages= 161-8 | pmid=24492208 | doi=10.1177/0194599813517659 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24492208  }} </ref>
+:::*Preferred regimen: [[Fluconazole]] 200 mg PO once <u>'''THEN'''</u> [[Fluconazole]] 100 mg PO q24h for 3–5 days
+::*'''1.3.2 Malignant otitis media, Pseudomonas aeruginosa'''<ref name="pmid24492208">{{cite journal| author=Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA et al.| title=Clinical practice guideline: acute otitis externa executive summary. | journal=Otolaryngol Head Neck Surg | year= 2014 | volume= 150 | issue= 2 | pages= 161-8 | pmid=24492208 | doi=10.1177/0194599813517659 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24492208  }} </ref>
+:::*Preferred regimen: [[Imipenem]] 0.5 g IV q6h {{or}} [[Meropenem]] 1 g IV q8h {{or}} [[Ciprofloxacin]] 400 mg IV q8h {{or}} [[Ceftazidime]] 2 g IV q8h {{or}} [[Cefepime]] 2 g IV q12h {{or}} ([[Piperacillin-Tazobactam]] 4-6g IV q4h {{and}} [[Tobramycin]] 3–5 mg/kg/day IV q8h)
+:::*Note: Oral [[Ciprofloxacin]] may be used by only in patients with very early disease
+*'''2. Otitis externa, chronic'''<ref name="pmid24492208">{{cite journal| author=Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA et al.| title=Clinical practice guideline: acute otitis externa executive summary. | journal=Otolaryngol Head Neck Surg | year= 2014 | volume= 150 | issue= 2 | pages= 161-8 | pmid=24492208 | doi=10.1177/0194599813517659 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24492208  }} </ref>
+:*'''2.1 Empiric antimicrobial therapy'''
+::*Preferred regimen: [[Neomycin]], [[Polymyxin B]], [[Hydrocortisone]] TOP q6-8h {{and}} [[Selenium Sulfide]] Shampoo
+::*Note: Selenium sulfide shampoo is recommended as the disease is usually secondary to seborrhea.
-===Malignant Otitis Externa===
+==Pain Management==
+Analgesia should be administered based on the severity of pain. Mild to moderate pain is usually managed with [[acetaminophen]] or [[nonsteroidal anti-inflammatory drugs]] given alone or in combination with an [[opioid]]. [[Fentanyl]], [[morphine]], and [[hydromorphone]] are indicated for procedure-related and moderate to severe pain.
-===Fungal Otitis Externa===
-===Chronic Otitis Externa===
-==Pain Management==
+==Algorithm for the Approach to Acute Otitis Externa==
-Analgesic agent should be administered based on the severity of pain.  Mild to moderate pain is usually managed with [[acetaminophen]] or [[nonsteroidal anti-inflammatory drugs]] given alone or in combination with an [[opioid]].  [[Fentanyl]], [[morphine]], and [[hydromorphone]] are indicated for procedure-related pain and moderate to severe pain.
+<span style="font-size: 85%;">
+'''Abbreviations''':
+AOE, acute otitis externa;
+TM, tympanic membrane.
+(Adapted from ''Clinical Practice Guideline: Acute Otitis Externa'')<ref>{{Cite journal| doi = 10.1177/0194599813517083| issn = 1097-6817| volume = 150| issue = 1 Suppl| pages = –1-S24| last1 = Rosenfeld| first1 = Richard M.| last2 = Schwartz| first2 = Seth R.| last3 = Cannon| first3 = C. Ron| last4 = Roland| first4 = Peter S.| last5 = Simon| first5 = Geoffrey R.| last6 = Kumar| first6 = Kaparaboyna Ashok| last7 = Huang| first7 = William W.| last8 = Haskell| first8 = Helen W.| last9 = Robertson| first9 = Peter J.| title = Clinical practice guideline: acute otitis externa| journal = Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery| date = 2014-02| pmid = 24491310}}</ref>
+</span>
-==Contraindicated medications==
+<div style="font-size: 70%;">
-{{MedCondContrAbs
+{{Familytree/start}}
-|MedCond = Viral otitis externa|Ciprofloxacin and dexamethasone otic suspension}}
+{{Familytree|boxstyle=border: 0;| | | | | X01 | | | | | | | | | | | | | | | | | | | | |X01={{F1|Diffuse AOE}}}}
+{{Familytree|boxstyle=border: 0;| | | | | |!| | | | | | | | | | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01={{F2|Analgesic based on severity}}}}
+{{Familytree|boxstyle=border: 0;| | | | | |!| | | | | | | | | | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | B01 | | | | | | | | | | | | | | | | | | | | |B01={{F1|Extension beyond ear canal or ⊕ factors requiring systemic Rx?}}}}
+{{Familytree|boxstyle=border: 0;| |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| C01 | | | | | | C02 | | | | | | | | | | | | | | | | |C01={{F1|YES}}|C02={{F1|NO}}}}
+{{Familytree|boxstyle=border: 0;| |!| | | | | | | |!| | | | | | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| D01 | | | | | | D02 | | | | | | | | | | | | | | | | |D01={{F2|Abx against ''P. aeruginosa'' and ''S. aureus''}}|D02={{F1|Perforated TM?}}}}
+{{Familytree|boxstyle=border: 0;| | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | E01 | | | | | | E02 | | | | | | | | | | | | |E01={{F1|YES}}|E02={{F1|NO}}}}
+{{Familytree|boxstyle=border: 0;| | | | | |!| | | | | | | |!| | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | F01 | | | | | | F02 | | | | | | | | | | | | |F01={{F2|Non-otoxic topical agent}}|F02={{F2|Topical agent}}}}
+{{Familytree|boxstyle=border: 0;| | | | | |`|-|-|-|v|-|-|-|'| | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | | | | | G01 | | | | | | | | | | | | | | | | |G01={{F1|Obstructed ear canal?}}}}
+{{Familytree|boxstyle=border: 0;| | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | H01 | | | | | | H02 | | | | | | | | | | | | |H01={{F1|YES}}|H02={{F1|NO}}}}
+{{Familytree|boxstyle=border: 0;| | | | | |!| | | | | | | |!| | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | I01 | | | | | | I02 | | | | | | | | | | | | |I01={{F2|Aural toilet or wick placement}}|I02={{F2|Educate pt on how to use ear drops}}}}
+{{Familytree|boxstyle=border: 0;| | | | | |`|-|-|-|v|-|-|-|'| | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | | | | | J01 | | | | | | | | | | | | | | | | |J01={{F1|Clinically improve in 3 days?}}}}
+{{Familytree|boxstyle=border: 0;| | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | K01 | | | | | | K02 | | | | | | | | | | | | |K01={{F1|YES}}|K02={{F1|NO}}}}
+{{Familytree|boxstyle=border: 0;| | | | | |!| | | | | | | |!| | | | | | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | L01 | | | | | | L02 | | | | | | | | | | | | |L01={{F2|Complete Rx course}}|L02={{F1|Illness other than AOE?}}}}
+{{Familytree|boxstyle=border: 0;| | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | | | | | M01 | | | | | | M02 | | | | | | | | |M01={{F1|YES}}|M02={{F1|NO}}}}
+{{Familytree|boxstyle=border: 0;| | | | | | | | | |!| | | | | | | |!| | | | | | | | | |}}
+{{Familytree|boxstyle=border: 0;| | | | | | | | | N01 | | | | | | N02 | | | | | | | | |N01={{F2|Treat accordingly}}|N02={{F2|Assess Rx adherence/delivery}}}}
+{{Familytree/end}}
+</div>
 ==References==
 {{reflist|2}}
-[[Category:Primary care]]
+{{WH}}
+{{WS}}
 [[Category:Disease]]
+[[Category:FinalQCRequired]]
+[[Category:Emergency mdicine]]
+[[Category:Up-To-Date]]
 [[Category:Infectious disease]]
-[[Category:Inflammations]]
 [[Category:Otolaryngology]]
 [[Category:Pediatrics]]
+[[Category:Immunology]]