Rosen & Barkin's 5-Minute Emergency Medicine Consult (499 page)

• Clean external ear canal:
  
  • Remove the inflammatory debris by gentle curettage with a cotton-tipped wire applicator
    
  • Occasional suction with a Frazier suction tip may be necessary
    
• Insert a cotton or gauze wick 10–12 mm into the canal after cleansing if the ear canal is very edematous
  
• Management of otitis externa focuses on pain control, eradication of infection, and prevention of reoccurrence
  

• Most cases respond well to topical treatment:
  
  • Antiseptic, anti-inflammatory, and drying otic drops eliminate the pathogenic bacteria and allow for rapid healing of the canal
    
  • Acetic acid solutions such as Domeboro otic (2% acetic acid): 4–6 drops q4–6h
    
  • Corticosporin otic (hydrocortisone 1%, polymyxin + neomycin) suspension: 4 drops to ear canal QID (use suspensions and not solutions with suspected TM perforation)
    
  • Ofloxacin: 5 drops BID (drug of choice in perforated TM)
    
• Oral antibiotics:
  
  • Administer to patients with cellulitis of the face or neck, severe edema of the ear canal, concurrent otitis media, or when the TM cannot be visualized
    
  • Treat diabetics and other immunocompromised patients with oral ciprofloxacin and follow closely for symptoms of malignant otitis externa
    
  • Amoxicillin: 500 mg (peds: 40 mg/kg/d) PO TID
    
  • Ciprofloxacin: 500 mg PO BID
    
• IV antibiotics for patients with necrotizing otitis externa, severe cellulitis, or septic appearing
  
• Prophylaxis:
  
  • Apply rubbing alcohol or acetic acid (2%) to keep the external ear canal dry and prevent recurrence of infection
    
• Pain management with acetaminophen or NSAID. Consider opioids if severe pain
  
• Surgical débridement of granulation tissue and bone sequestration or drainage of associated abscess may be necessary in necrotizing otitis externa
  

• Mastoiditis
  
• Chondritis of the auricle
  
• Necrotizing otitis externa
  
• Osteomyelitis of the base of the skull
  
• CNS infections
  

FOLLOW-UP

• Necrotizing otitis externa
  
• Significant involvement of the pinna
  
• Signs of systemic illness
  

• Most patients
  
• Close follow-up for patients at risk of otitis externa
  
• Patient instructions:
  
  • Avoid swimming and keep ears completely dry for 3–4 wk
    
  • Apply medications as directed
    
  • Return if worse pain, fever, hearing loss develops, or there is any change in mental or neurologic status
    
  • Follow up if symptoms are not improved within 2–3 days
    

Ear–nose–throat follow-up for:

• Perforated TM
  
• Worsening of symptoms
  
• Conductive hearing loss
  
• Failure of initial management
  

Follow up with primary care physician or a return ED visit within 2–3 days for removal of the wick or if symptoms are worse.

• Concomitant and often erroneous diagnoses of acute otitis externa and otitis media are common because the TM in acute otitis externa is erythematous.
  
• Avoid ear canal lavage until tympanic integrity is documented.
  
• Regardless of the topical medications, penetration to the epithelium is key to therapy; any obstruction should be cleared.
  
• Recurrence can be largely prevented by counseling the patient and explaining how it can be avoided by minimizing ear canal moisture, trauma, or exposure to material that incites local irritation or contact dermatitis.
  
• Necrotizing otitis externa should be suspected in immunocompromised patients and diabetics who have severe otalgia, purulent otorrhea, and granulation tissue or exposed bone in the external auditory canal.
  

• Birchall JP. Managing otitis externa.
  Practitioner
  . 2006;250:78–82.
  
• Carfrae MJ, Kesser BW. Malignant otitis externa.
  Otolaryngol Clin North Am
  . 2008;41:537–549.
  
• Collier SA, Hlavsa MC, Piercefield EW, et al. Antimicrobial and analgesic prescribing patterns for acute otitis externa, 2004--2010.
  Otolaryngol Head Neck Surg
  . 2013;148:128–134.
  
• Osguthorpe JD, Nielsen DR. Otitis externa: Review and clinical update.
  Am Fam Physician
  . 2006;74:1510–1516.
  
• Stone KE. Otitis externa.
  Pediatr Rev
  . 2007;28:77–78.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Otitis Media
  
• Mastoiditis
  
• Tympanic Membrane Perforation
  

CODES

• 380.10 Infective otitis externa, unspecified
  
• 380.14 Malignant otitis externa
  

BASICS

• Inflammation of the middle ear
  
• Most commonly occurs in children 6–36 mo
  
• Rapid onset of local and/or systemic symptoms
  
• More than 1/3 of children experience >5 episodes by the age of 7 yr
  

• Usually associated with (or as a result of) upper respiratory tract infections
  
• Viral:
  
  • Parainfluenza
    
  • Respiratory syncytial virus
    
  • Influenza
    
  • Adenovirus
    
  • Rhinovirus
    
• Bacterial:
  
  • Streptococcus pneumoniae
    
  • Moraxella catarrhalis
    
  • Haemophilus influenzae
    
  • Streptococcus pyogenes
    
  • Mycoplasma pneumoniae
    
• Associated with blockage of eustachian tube
  
• Predisposing factors:
  
  • Deficient mucus, cilia, or antibodies
    
  • Intubation, especially nasotracheal
    
  • American Indians, Eskimos
    
  • Down syndrome
    
  • Cleft palate
    
  • Diabetes
    
  • Vitamin A deficiency
    
  • HIV
    
• Risk factors
  
  • Family history
    
  • Daycare
    
  • Parental smoking
    
  • Pacifier use
    
  • Bottle-feeding
    

DIAGNOSIS

From the American Academy of Pediatrics 2013 Guidelines:

• Diagnose otitis media (OM) when:
  
  • Moderate to severe bulging of tympanic membrane (TM)
    
  • Mild bulging of TM
    and
    recent onset of ear pain (tugging, pulling, rubbing in nonverbal child)
    
  • New otorrhea not due to acute otitis externa
    
• Should
  not
  diagnose if no middle ear effusion (pneumatic otoscopy and/or typanometry)
  
• Recurrent OM:
  
  • 3 episodes in 6 mo or
    
  • 4 episodes in the last year with 1 in the past 6 mo
    

• Ear pain (otalgia)
  
• Irritability
  
• Rhinitis
  
• Vomiting, diarrhea
  
• Poor feeding
  
• Fever
  
• Sensation of plugged ear
  
• Pulling at ear
  
• Vertigo, tinnitus
  
• Conjunctivitis
  

• TM inflammation, bulging, and limited mobility
  
• New onset otorrhea without evidence of otitis externa
  
• Decreased visibility of the landmarks of the middle ear
  

• Exclude associated conditions
  
• Consider full septic workup for sick patients with fever
  
• Otoscopic exam for appearance and mobility of TM:
  
  • Full visualization essential
    
  • Increased vascularity, erythema, purulence
    
  • Obscured landmarks—bony, light reflex
    
  • Pneumatic otoscopy—bulging, retracted, decreased mobility