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Acute Otitis Externa (AOE)

Overview
Acute otitis externa, colloquially known as “swimmer’s ear”, is an acute inflammation of the external auditory canal (EAC) with a typically infectious etiology and is frequently seen and treated by primary care providers who consult our specialty when patients have recurrent, severe, or unresponsive disease. The common presenting symptoms include otalgia, otorrhea, aural fullness, pruritis and hearing loss. On examination, traction of the pinna or pressure on the tragus typically results in significant pain. In some cases, concomitant parotid gland swelling can be seen, secondary to the connection between the anterior EAC and parotid space via the fissures of Santorini. The pathogenesis of OAE is thought to begin with disruption of the cerumen of the EAC which normally forms a mechanical barrier and helps maintain the protective acidic environment. This can be caused by mechanical trauma from cotton swab and hearing aid use or from retained moisture from water exposure, EAC masses, or dermatologic conditions such as psoriasis or eczema. Mechanical disruption and moisture cause epithelial damage allowing for growth of pathologic bacteria or fungi; most commonly Pseudomonas aeruginosa followed by Staphylococcus species. Fungal otitis externa, while uncommonly the offending pathogen in acute otitis externa, is thought to play a more significant part in chronic otitis. Diabetic and other immunocompromised patients are at higher risk for OE.

Key Supplies for Consultation

  • Appropriate PPE including mask, eye protection, gloves, and gown

  • Otoscope

  • Cerumen currette

  • Consider culture swab

  • Ear wick with small alligator forceps for placement

  • If cleaning debris from the ear canal, will need operating microscope, size 3, 4 or 5 ear speculums, size 5 or size 7 straight suction, suction source

Management

  • Comprehensive history with attention to otologic history including Q-tip or hearing aid use, water exposure, and skin conditions such as psoriasis and eczema

  • Complete head and neck exam with tuning fork tests (may need to repeat after debridement if EAC is occluded)

  • Treatment focuses on drying (and debriding) the ear canal, acidifying the ear canal, and eradicating infectious pathogens

  • Debride the ear canal meticulously, inspect the tympanic membrane (TM) for perforations (avoid ototoxic, acidic, or alcohol drops if present) and survey for signs of other diseases (Ramsey-Hunt syndrome, cancer of the EAC, bullous myringitis, otitis media, etc.)

  • Culture of the EAC drainage is indicated if the disease is severe or extending beyond the EAC, patient is immunosuppressed, or unresponsive to prior treatment

  • Place cotton otowick if canal edema is severe and prohibits ototopical medication from reaching the TM

  • To place, grasp the end of the otowick with a medium sized alligator forceps; while visualizing the canal under binocular microscopy, slowly advance the end of the wick till it is bridging the most inflamed portion of the EAC being careful not to plunge the wick into the TM; may need to place two wicks side-by-side if the entire canal is edematous. If case is mild and TM intact, mixture of white vinegar (acidifies the EAC) and rubbing alcohol (dries the EAC) is very effective, can also use acetic acid or acetic acid with aluminum acetate

  • Antibiotics drops with or without steroids for moderate or severe disease, see common commercially available options below:

    • Ciprodex (ciprofloxacin and hydrocortisone): widely available and well-tolerated, can be expensive

    • Ciprofloxacin drops: widely available and less expensive compared to Ciprodex, however lacks steroid component, which may be helpful with canal edema

    • Cortisporin (polymyxcin, neomycin, and hydrocortisone): widely available, inexpensive, but has high (>10%) incidence of atopic reactions to neomycin

  • Explain proper application technique: contralateral ear on pillow, place drops in affected EAC, press or “pump” tragus till drops are felt against ear drum (this can be painful for patients)

  • Reserve systemic antibiotics for cases with extension beyond the ear canal (auricular chondritis or facial extension), patients with immune compromise or poorly controlled diabetes, or patients with a history of temporal bone irradiation 

  • Dry ear precautions for minimum of two weeks following symptomatic resolution 

  • Patients can usually be managed as an outpatient with reassessment and debridement in 2-3 days. If patient has not improved at that time, consider more advanced disease such as malignant otitis externa, antimicrobial resistance, contact dermatitis to prescribed drops, noncompliance or poor application technique, tuberculosis, squamous cell cancer of EAC and other rare pathology

 We recommend the AAO-HNSF Clinical Practice Guideline for Acute Otitis Externa for additional reading on this topic.

Chondritis/Periauricular Cellulitis

Overview
Spread of infection from an acute otitis externa to the periauricular soft tissue or auricular cartilage and skin is unusual but requires immediate identification and initiation of systemic antibiotics in additional to the treatment of the otitis externa with the treatments outlined above. Chondritis of the ear is much more commonly seen following trauma to auricle such as with cartilage piercings, lacerations or bug bites. Signs of chondritis include auricular flaking, loss of natural folds of pinna, erythema, weeping, and tenderness with eventual abscess formation and liquefactive necrosis of cartilage. Early identification of abscess formation improves outcomes if drained to prevent impending ischemia of the cartilage. Auricular chondritis can have a dramatic cosmetic impact leaving the patient with “cauliflower ear” or complete loss of recognizable structures of the auricle. Systemic antibiotics with cartilage penetration are generally required. Fluroquinolones are the preferred antibiotic choice due to their cartilage penetration, though local antibiograms must be considered as Pseudomonal resistance to fluroquinolones nears 30% in some areas. If fluoroquinolones are prescribed, patients should be counseled on the associated risk of tendinopathy and arthropathy though this can typically be managed by stopping the antibiotic without lasting deleterious effect. Parenteral antibiotics should be considered in children or any adult with severe disease or immunosuppresed state.

Management

  • Basic history (including any recent trauma to the auricle) and physical exam with attention to the middle ear, mastoid (ensure no mastoid tenderness or fluctuance) and external ear with detailed documentation of the extent of the infection (facilitates tracking response to treatment) 

  • Drain any auricular abscess if present, usually just needle aspiration or small stab incision with 15-blade then flush thoroughly with saline, apply topical antibiotic ointment, cover with xeroform or antibiotic impregnated gauze

  • Debride clearly necrotic cartilage if present but avoid overly aggressive debridement

  • Obtain cultures from the abscess if present or if able to express any purulence from the auricle

  • No imaging indicated unless concern for malignant otitis externa or mastoiditis 

  • Labs generally not necessary unless systemic symptoms are present

  • Initiate systemic antibiotics:

    • Ciprofloxacin 500mg BID PO for 10 days for adults is a reasonable option

    • If allergic to fluoroquinolones, consider parenteral piperacillin-tazobactam or combination penicillin and aminoglycoside vs carbapenem if severe disease

    • Counsel all patients but especially pediatric patients on the risk of arthropathy and tendinopathy if fluoroquinolones prescribed   

  • In mild cases, can be managed as outpatient, with close follow-up within 2-3 days. More severe cases may require admission for intravenous antibiotics

Malignant Otitis Externa (MOE)

Overview
Malignant otitis externa, or osteomyelitis of the temporal bone, is a severe progression of otitis externa. This generally develops over the course of several weeks and occurs almost exclusively in immunocompromised or diabetic patients. Classic findings include pain out of proportion on exam and granulation tissue at the osseocartilaginous junction floor. As in uncomplicated otitis externa, the most common pathogen is Pseudomonas aeruginosa followed by Staphylococcus species. Spread of the infection along the skull base can lead to cranial nerve weakness (predominantly affecting the facial nerve), bony erosion, and intracranial involvement (meningitis, abscess, venous sinus thrombosis). The long term prognosis of this disease is variable (10-20% mortality), but patients with reversible underlying disease, such as diabetes, typically have improved prognosis.

Management 

  • Complete history with focus on any prior otologic history, immunosuppression, and temporal bone radiation

  • Complete detailed head and neck exam with focus on the EAC and middle ear, cranial nerves, and hearing using tuning fork tests

  • Debride the ear canal thoroughly

  • Culture of drainage and antibiotic sensitivity studies are useful to guide long-term antibiotic selection

  • Laboratory tests should include CBC, CMP, CRP, ESR, and blood cultures if patient is showing systemic symptoms

  • Imaging is indicated in all suspected cases of MOE:

    • High-resolution temporal bone CT: excellent for assessment of bony erosion, however, underestimates soft tissue and intracranial involvement

    • MRI IAC and brain with and without contrast: demonstrates intracranial disease extent

    • Nuclear medicine Technetium-99 scan is the traditional diagnostic imaging modality of choice due to its high sensitivity to osteoblastic activity before bony destruction would be visible on CT. Osteoblastic activity continues after infection resolution, however, so this scan cannot be used to monitor progress after diagnosis

    • Gallium-67 radiolabeled leukocyte study detects active inflammation and is useful for monitoring resolution of infection.

  • Start systemic antibiotics, generally requires inpatient admission

    • Mild cases with early detection can be treated with oral antipseudomonal such as ciprofloxacin for 1-6 months

    • Moderate or severe cases require intravenous antibiotic therapy with antipseudomonal coverage. Culture data can direct treatment and Infectious Disease can be consulted to guide antibiotic management

    • Most patients will require a minimum of 4-week course of antibiotics (continuation of antibiotics till Gallium-67 scans demonstrates resolution of disease)

  • Medical management and reversal of underlying immunocompromising disease state may improve prognosis

  • Close inpatient monitoring of otologic symptoms and cranial nerve status

  • Surgical treatment is infrequently required and is reserved for cases with abscess development and rarely for persistent disease that does not resolve with long-term antibiotic treatment

Example Procedure Note 

  • Procedure: ear canal cleaning and placement of ear wick
    After obtaining written and verbal consent, the patient’s head was turned and an ear speculum was gently inserted. The ear canal appeared ___. Debris was gently removed the from external auditory canal using ___  (insert here if culture obtained). Care was taken to ensure the tympanic membrane was not violated. Next, an ear wick was gently inserted and inflated using ototopical drops. The patient tolerated the procedure relatively well.

References

  1. Linstrom, C.J., Lucente, F.E. (2013). Diseases of the External Ear. In J.J. Johnson, C.A. Rosen. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 2333-2357). Baltimore, MD: Lippincott Williams & Wilkins. 

  2. Naples, J.G., et al (2020). Infections of the External Ear. In P.W. Flint, et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 2093-2100). Philadelphia, PA: Elsevier.

  3. Rosenfeld, R. M., Schwartz, S. R., Cannon, C. R., Roland, P. S., Simon, G. R., Kumar, K. A., … Robertson, P. J. (2014). Clinical Practice Guideline: Acute Otitis Externa. Otolaryngology–Head and Neck Surgery, 150(1_suppl), S1–S24. https://doi.org/10.1177/0194599813517083