Otitis Externa

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Circumscript Otitis Externa (Furunculosis)

This is a localized infection of the hair follicle on the outer one-third of the external auditory canal. It  is caused by Staphylococcus aureus

Clinical Presentation

  • Ear pain that is severe and disproportional to the visible lesion
  • Reduced hearing
  • Localized swelling on the external auditory canal
  • There may be a purulent discharge if the swelling ruptures

Non-Pharmacological Management

  • Aural toilet if there is otorrhea (ear suctioning under direct vision).

  • Instruct the patient to keep the ear dry and avoiding scratching

Pharmacological Management

B:  ampicillin + cloxacillin  (FDC)  (PO)  Adults:  500mg  8hourly  for  7  to  10days Children: 15mg/kg hourly for 7 to 10days  
OR 

C: amoxycillin + clavulanic acid (FDC) (PO) Adults: 625mg to 1g 12hourly for 7 to 10days. 

Children ≤ 3 months: 30mg/kg/day in 2 divided doses for 7-10 days.

Children >3 months:  25mg/kg/day in 2 divided doses for 7 to 10 days. 

AND 

A:  paracetamol  (PO)  Adults:  500mg  to  1g  4  to  8hourly  as  needed. 

Children  ≤  10kg: 10mg/kg 4 to 8 hourly as needed. Children >10kg: 15mg/kg   4 to 8 hourly as needed 

OR 

A: ibuprofen (PO) Adults: 200 mg to 400mg 4 to 8hourly as needed.

Children ≥ 6 months: 5mg to 10mg/kg 4 to 8hourly as needed OR combined ibuprofen and paracetamol

Surgical Management

  • Incision and drainage

Diffusewer Otitis Externa (Swimmer’s ear)

This is an inflammation of the entire external auditory canal. It can be caused by bacteria, fungus or both. 

Clinical Presentation

  • Itchy, dry and scaly ear canal and painful ear

  • There may be a water or purulent discharge, debris and reduced hearing

Pain may become extreme when the ear canal becomes completely occluded with edematous skin and debris. 

Non-Pharmacological Management

  • Aural toilet at least once a week (ear suctioning under direct vision using microscope or endoscope).

  • Instruct the patient to keep the ear dry and avoiding scratching

Pharmacological Management

C: ciprofloxacin ear drops 2 to 4drops each ear 6 to 8hourly for 14 days

OR 

C: cream with combination of gentamicin or neomycin+ clobetasol or betamethasone or beclometasone+miconazole or clotrimazole. Dosage: Apply pea size in external auditory  canal once per week for 4 to 6weeks

OR 

D:  chloramphenicol +beclomethasone  dipropionate +  clotrimazole  +  lignocaine  ear drops (FDC) 2 to 3drops each ear 6 to 8hourly for 14days

AND 

A: ciprofloxacin (PO) 500mg: Adults and children above 12 years 12 hourly 7 to 14 day 

OR 

B: amoxycillin +clavulanate (FDC) (PO)

Adult 625mg to 1g 12hourly

Paediatric ≤ 3 month: 30mg/kg/day in 2 divided doses.

Paediatric ˃ 3 month: 25mg/kg/day in 2 divided doses for 7-14days 

AND 

A: paracetamol (PO)

Adult 1g

Pediatric ≤ 10kg: 10mg/kg Paediatric >10 kg: 15mg/kg 6 to 8 hourly as needed. 

OR 

A: ibuprofen (PO) 200 mg to 400mg 8 hourly as needed. Paediatric ≥ 6 months: 5mg to 10mg/kg 4 to 8hourly as needed 

OR 

D:  diclofenac +  paracetamol  (PO)(FDC)

Adults: 50mg  diclofenac  and  500mg  paracetamol 4 to 8hourly as needed.

Necrotizing Otitis Externa

This is a life-threatening infection that affects the external auditory canal and base of the skull. It is  common  to  elderly  diabetic  patients  and  other immunosuppressive conditions.  Most  common  causative organism is Pseumonas  aureginosa. Controlling   the underlying cause of  immunosuppression is of paramount importance.  

Clinical Presentation

  • Ear pain, discharge, fullness and hearing impairment
  • May present with facial nerve paralysis or other cranial nerves palsy
  • Presence of granulation tissues at the junction between the bony and cartilaginous parts of external auditory canal
  • Necrosis of external auditory canal

Non-Pharmacological Management

  • Aural toilet at least once a week (ear suctioning under direct vision using microscope or endoscope)

  • Instruct the patient to keep the ear dry and avoiding scratching

Investigations

  • culture and sensitivity of discharge

Pharmacological Management

C: ciprofloxacin ear drops 2 to 4 drops each ear 6 to 8hourly for 14days 

AND 

B: ceftriaxone (IV) 1 to 2 g 12hourly for 7days

For Children:  

B: ceftriaxone (IV) 50 to 100mg/kg 24hourly for 7 day 

OR 

C: ciprofloxacin (IV) 400mg for 5 to 7days THEN 500mg (PO) 12hourly for 4 to 6weeks 

OR 

S: meropenem (IV) (culture and sensitivity test is required) 500mg to 2g 8 hourly for 7 to 14days

For Children ≥ 3 months: 

S:  meropenem  (IV)  (culture  and  sensitivity  test  is  required)  10mg/kg  8  hourly  for  7  to 14 days

AND 

A: paracetamol (IV) 500mg to 1g 4 to 8hourly as needed

For Children ≤ 10kg: 

A: paracetamol (IV) 10mg/kg 4 to 8hourly as needed. 

For Children >10kg:  

A: paracetamol (IV) 15mg/kg 4 to 8hourly as needed

OR 

A: ibuprofen (PO) 200 to 400mg 4 to 8hourly as needed

For Children ≥ 6 months:  

A: ibuprofen (PO) 5mg to 10mg/kg 4 to 8hourly as needed 

OR 

C: diclofenac+ paracetamol (PO) 50mg diclofenac and 500mg paracetamol 4 to 8hourly as needed

Surgical Management

  • Serial surgical debridement under local anesthesia(LA) or general anesthesia (GA)

Note: Necrotizing otitis externa is an emergency therefore treatment should be vigorous including  the treatment of underlying immunodeficiency. Consider referral to tertiary facility for specialized care.