Central Annals of Otolaryngology and Rhinology

Review Article *Corresponding author

Otitis Externa: And Update

Jose Luis Treviño González, Av. Madero y Gonzalitos
Colonia Mitras Centro, Monterey, México, Tel: 83334846;
Email:
Submitted: 20 September 2017
José Luis Treviño González* and Karla Durán Moreno
Accepted: 24 October 2017
Department of Otolaryngology and Head and Neck Surgery, School of Medicine,
Published: 26 October 2017
University A. of Nuevo León, México
ISSN: 2379-948X
Copyright
Abstract
© 2017 Treviño González et al.
Acute otitis externa is the inflammation and infection of the external auditory canal. The acute
form can be classified as diffuse otitis externa, which is the most common form of OE, and localized OPEN ACCESS
otitis externa. This pathology occurs primarily in swimmers because of the prolonged exposure to
water, but it can also be caused by minor traumas in an inappropriate cleaning. Pseudomonas Keywords
aeruginosa and Staphylococcus aureus are the most common pathogens found in AOE. • Acute otitis externa
• Treatment guideline
Signs and symptoms include otalgia, itching, canal edema, erythema and otorrhea. The most • Otitis externa maligna
significant sign is soreness of the tragus with movement. • Drug resistance
Diagnosis is clinical with help of an otoscope to have a direct and clearer view.
For the management of acute otitis externa, a combination of measures is necessary. The
most important step is an exhaustive cleaning or aspiration of the ear canal, so there is a correct
penetration of the drug therapy.
Treatment for AOE involves acidifying agents alone, acidifying agents with steroids, or
antibiotics with steroids. This last one is the most recommended treatment, being Ciprofloxacin the
first line of treatment in antibiotics.

ABBREVIATIONS
AOE: Acute Otitis Externa; EAC:External Auditory Canal; OE:
Otitis Externa
INTRODUCTION
Acute otitis externa is a condition that involves inflammation
of the external ear canal which may extend laterally to the pinna
and proximally to the tympanic membrane resulting in otalgia,
itching, canal edema, erythema and otorrhea. Soreness with
movement of the tragus or pinna is a classic finding.
This pathology often occurs after swimming or minor trauma
from inappropriate cleaning. Local defense mechanisms become
disabled by prolonged ear canal wetness, and skin desquamation
leads to microscopic fissures that provide a portal of entry for
infecting organisms. The acute diffuse form, which is this review
main issue, is caused primarily by bacterial infection, with
Pseudomonas aeruginosa and Staphylococcus aureus as the most
common pathogens [1,2].
Each year, otitis externa is reported to affect four out 1000
Americans of all age groups, and it affects males and females
equally. The incidence is highest in children. A study from US
reported that from 2003 to 2007, rates of ambulatory visits for
otitis externa were highest among children 5-9 years and 10-14
years [3,4].
Classification
Acute otitis externa can be classified based on its etiology,
location and time course of illness. These include acute diffuse
otitis externa, which is the main subject in this review, acute
localized otitis externa, otomycosis, herpes oticus, dermatoses
and malignant otitis externa [5].
Microbiology
The bacterial flora of the EAC is predominantly composed
of gram positive organisms. The most commonly recognized
microorganisms are Staphylococcus epidermidis (38%) and
Diptheroid (22.4%). Gram negative organisms are less prevalent,
isolated from <5% of the external auditory canal specimens.
Following prolonged water exposure, however, the flora of the
EAC changes, becoming dominated by gram negative organisms.
Pseudomonas aeruginosa is the most frequent pathogen
in AOE, identified in 22-62% of cases in series on AOE.
Staphylococcus aureus (11-34% of cases) is the most important
gram positive pathogen [5-8].
Risk factors
There are several factors that can cause AOE, one of them
being associated with dermatological disease of the ear canal
and conchal bowl, such as eczema and, less commonly, psoriasis.
These abnormalities are more common in swimmers, humid
environments, in people with narrow external ear canals, in
hearing aid users, and after mechanical trauma or ear syringing
[9-11]. Otitis externa may also occur secondary to ear canal
obstruction by impacted cerumen, foreign object, a dermoid cyst,
sebaceous cyst, or furuncle [12].

Cite this article: Treviño González JL, Moreno KD (2017) Otitis Externa: And Update. Ann Otolaryngol Rhinol 4(8): 1195.

Central
Diagnosis
The diagnosis of AOE is primarily clinical. The clinical
history should identify predisposing factors including exposure
to potentially contaminated water or mild trauma from
inappropriate cleaning.
Symptoms include otalgia (70%), itching (60%), or fullness
(22%), with or without hearing loss (32%) or ear canal pain
on chewing. A hallmark sign of diffuse AOE is tenderness of the
tragus, the pinna, or both, when manipulated [12].
Otoscopy will reveal diffuse ear canal edema, erythema, with
or without otorrhea. Regional lymphadenitis or cellulitis of the
pinna and adjacent skin may be present in some patients [12].
Apart from the typical acute form of otitis externa, special
forms can appear such as an acute localized otitis externa, which
originates from a hair follicle, or otitis externa necroticans
(“maligna”), which can take a fulminant course and therefore
requires intravenous treatment [13].
Treatment
There are 5 fundamental steps in the management of external
otitis: cleaning the ear canal, treat inflammation and infection,
control pain, avoid promoting factors, and follow up [14].
The most important step in treating an AOE is an exhaustive,
gentle cleansing, suction and instrumentation of the external
auditory canal under direct microscopic inspection. This
facilitates healing and enhances penetration of ear drops into the
site of inflammation.
Sometimes the debris is hard, crusted and difficult to take out,
in those cases, topical otic drops or hydrogen peroxide can help
softening the canal’s content. The frequency of canal cleansing
depends on the amount of debris and secretion, and may vary
from once every 1 to 5 days [15].
Once the external auditory canal is clean, the next step is
the topical drug therapy. A topical approach is considered to
be better than oral antibiotics or surgery, because the disease
is limited to the skin of the ear canal. The treatment includes
acidifying agents, and topical antibiotics. Topical corticosteroids
and non steroidal anti-inflammatory drugs can also be employed,
to assist in the resolution of the local edema and pain relief [15].
Acidifying solutions (Antiseptics)
Antiseptics function as bacteriostatic agents; they make the
ear canal less habitable for bacteria and may loosen debris in
the ear canal. P. aeruginosa and S. aureus, which are the most
common pathogens, need an optimal pH between 6.5 and 7.3
in the ear canal to have perfect growing conditions, they do not
grow well in a lower pH. That’s why by simply acidifying the ear
canal, bacterial growth inhibition occurs. Some of the antiseptics
used are aluminium acetate and acetic acid 2%.
Acidifying solutions are well tolerated, but may be associated
with local irritation manifested by burning or stinging. Acetic
acid can be applied as monotherapy or it can be combined
with steroids, such as hydrocortisone, when managing an
uncomplicated AOE [16].
Ann Otolaryngol Rhinol 4(8): 1195 (2017)
Treviño González et al. (2017)
Email:
Topical antibiotics
When there is a moderate to severe form of otitis externa, the
current gold standard treatment is topical antibiotics in the form
of ear drops, which may also contain topical steroids. Sometimes
the auditory canal is occluded and needs an ear wick insertion,
which can be gauze, or aperformed cellulose sponge, to help the
canal expand and have an appropriate penetration of the topical
solution. When indicated, a return visit in two to three days for
removal of the wick is necessary [17].
Certain factors should be considered when selecting an
ototopical antibiotic: coverage of specific pathogens, side effect
profile, and drug resistance.
The ideal antibiotic regimen should have specific coverage
against the most common pathogens, P. Aeruginosa and S. aureus.
For example fluoroquinolones like ofloxacin and ciprofloxacin
provide excellent coverage against both pathogens, as well as
aminoglycosides, tobramycin and gentamicin.
Ciprofloxacin ranks among the most effective fluoroquinolone
against P. aeruginosa; it has a broad spectrum and acts as a
bactericide, particularly against gram negative pathogens, and
is moderately effective against gram positive pathogens. Topical
ciprofloxacin constitutes the first line of treatment in severe
otitis externa in children and adolescents [18].
Concerning the side effect profile, ototoxicity is the most
important concern with aminoglycoside agents. There is a
significant potential source for iatrogenic hearing loss and
balance dysfunction, particularly in the presence of tympanic
membrane perforation. Allergic contact dermatitis is commonly
associated with neomycin when used for prolonged courses [19].
Contrariwise, the side effect of fluoroquinolones is local
irritation, and there is no risk of ototoxicity [19].
Inflammation and pain control
Adequate pain control for mild to moderate AOE can be
achieved with sistemic acetaminophen, non steroidal anti-
inflammatory medications or oral opioid preparations. Topical
steroids preparations have mixed effects on hastening pain relief
but are not recommended as monotherapy [20,21].
Studies showed significant improvement with steroid and
antibiotic combination when compared with only antibiotic
drops [22].
Drug resistance
There is certain concern that some patients develop a drug
resistant form of otitis externa. This resistance is more common
in infections caused by bacterial (66%) and fungal (15%)
microorganisms. The most common pathogens are Pseudomonas
species and S. Aureus. In a prospective study, it was observed 100%
resistance of Pseudomonas species to neomycin, chloramphenicol,
trimethoprim and amoxicillin, while all isolates were sensitive
to polymyxin B and ciprofloxacin. Sensitivity to gentamicin was
98.5%. S. Aureus isolates showed no evidence of resistance to
gentamicin and flucloxacillin. 92.3% of isolates were sensitive
to neomycin and chloramphenicol. In view of this, polymyxin B,
gentamicin or ciprofloxacin topical preparations should be used
as first line treatment for otitis externa in secondary care [23,24].
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DISCUSSION & CONCLUSION
Acute otitis externa is a frequent health problem in young
ages and there are many factors that can avoid the development
of this disease, especially if physicians dedicate time to educate
patients in how to avoid recurrences of AOE. The most important
issue is to avoid complications, which are not that frequent but
can be deadly.
The correct management of diffuse external otitis is simple,
and as mentioned in the review, topical preparations such as
ciprofloxacin make it easier to avoid side effects and give a more
complete and effective therapy.
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Cite this article
Treviño González JL, Moreno KD (2017) Otitis Externa: And Update. Ann Otolaryngol Rhinol 4(8): 1195.
Ann Otolaryngol Rhinol 4(8): 1195 (2017)
Treviño González et al. (2017)
Email:
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