A guide to managing disorders of the ear pinna and canal
This review will help you troubleshoot everything from infections and foreign bodies to trauma and neoplasm.
PRACTICE RECOMMENDATIONS
› Prescribe topical antibiotics for uncomplicated otitis externa, reserving systemic agents for infection extending outside the ear canal, necrotizing otitis externa, or patients who are immunodeficient. C
› Avoid clearing cerumen if a patient is asymptomatic and advise patients/parents on Do’s and Don’ts for ear wax accumulation. C
› Consider flooding the ear canal with xylocaine, alcohol, or mineral oil before attempting insect removal. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
How to treat. The cornerstone of treatment is early detection and antimicrobial coverage with antipseudomonal antibiotics. Ciprofloxacin is the oral antibiotic of choice because of its ability to penetrate the tissue.4 Other options include clindamycin and third- or fourth-generation cephalosporins. If the wound becomes abscessed, perform (or refer for) early surgical incision and drainage.5 A failure to promptly recognize perichondritis or to mistakenly prescribe non-antipseudomonal antibiotics contributes to increased rates of hospitalization.2 Cosmetic deformity is the most common complication of perichondritis. This may require reconstructive surgery.
Otitis externa
Acute otitis externa (AOE; “swimmer’s ear”) is cellulitis of the skin and subdermis of the external ear canal. It is most prevalent in warm, moist climates and almost always associated with acute bacterial infection, most commonly P aeruginosa or S aureus.6 There is also an increased association with poor water quality (containing higher bacterial loads). Anything breaching the integrity of the ear canal can potentially predispose to the development of AOE. This includes trauma from cleaning, cerumen removal, scratching due to allergic conditions, and placement of hearing-aid devices.6
What you’ll see. Suspect AOE when signs or symptoms of ear canal inflammation have appeared rapidly (generally within 2 days) over the past 3 weeks.7 Findings include otalgia, itching, fullness, tragal tenderness, ear canal edema, erythema with or without otorrhea, lymphadenitis, or cellulitis of the pinna or adjacent skin.7 AOE must be distinguished from other causes of otalgia and otorrhea, including dermatitis and viral infection.
How to treat. Topical therapy is recommended for the initial treatment of uncomplicated AOE, usually given over 7 days. Multiple topical preparations are available, such as ciprofloxacin 0.2%/hydrocortisone 1.0%; neomycin/polymyxin B/hydrocortisone; ofloxacin 0.3%; or acetic acid 2.0%.7 Avoid these agents, though, if you suspect tympanic membrane rupture. Quinolone drops are the only topical antimicrobials approved for middle ear use.7
Systemic antibiotics are not recommended for the initial treatment of AOE. Topical agents deliver a much higher concentration of medication than can be achieved systemically. Consider systemic antibiotics if there is extension outside the ear canal, a concern for necrotizing otitis externa (more on this in a bit), or the patient is immunodeficient.8
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