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PRACTICE POINT
Acute otitis externa
Charles PS Hui; Canadian Paediatric Society
Infectious Diseases and Immunization Committee
Paediatr Child Health 2013;18(2):96-98
Posted: Feb 1 2013 Reaffirmed: Feb 1 2016
Abstract
Acute otitis externa, also known as ‘swimmer’s ear’, is a com­
mon disease of children, adolescents and adults. While chronic
suppurative otitis media or acute otitis media with tympanosto­
my tubes or a perforation can cause acute otitis externa, both
the infecting organisms and management protocol are different.
This practice point focuses solely on managing acute otitis exter­
na, without acute otitis media, tympanostomy tubes or a perfora­
tion being present.
Key Words: Acute otitis externa; Swimmer’s ear
scopy, the canal is edematous and erythematous and may be
associated with surrounding cellulitis.[4] There may be celluli­
tis or chondritis of the pinna.
Elements to consider in the diagnosis of diffuse acute otitis
externa:
1. Rapid onset (generally within 48 h) in the past three weeks
AND
2. Symptoms of ear canal inflammation, including
• otalgia (often severe), itching or fullness
Acute otitis externa (AOE), also known as ‘swimmer’s ear’, is
a common disease of children, adolescents and adults. It is
defined by diffuse inflammation of the external ear canal. Pri­
marily a disease of children over two years of age, it is com­
monly associated with swimming. Local defence mechanisms
become impaired by prolonged ear canal wetness. Skin
desquamation leads to microscopic fissures that provide a por­
tal of entry for infecting organisms.[1] Other risk factors for
AOE include: trauma, a foreign body in the ear, using a hear­
ing aid, certain dermatological conditions, chronic otorrhea,
wearing tight head scarves and being immunocompromised.
Ear piercing may lead to infection of the pinna.[2][3] While
AOE is primarily a local disease, more serious and invasive
disease can occur in certain situations. Several evidence-based
clinical practice guidelines and reviews have been published.
[4]-[8]
Clinical presentation
Typically, patients present with otalgia (70%), itching (60%),
or fullness (22%), with or without hearing loss (32%) or ear
canal pain when chewing. Many patients with AOE have dis­
charge from their ear canal. A distinguishing sign of AOE
from acute otitis media with otorrhea is the finding of tender­
ness of the tragus when pushed and of the pinna when pulled
in AOE. These signs are classically described as out of propor­
tion to the degree of inflammation observed. On direct oto­
• WITH OR WITHOUT hearing loss or jaw pain*
AND
3. Signs of ear canal inflammation, including
• tenderness of the tragus, pinna, or both
OR
• diffuse ear canal edema, erythema, or both
• WITH OR WITHOUT otorrhea, regional lymphadenitis,
tympanic membrane erythema, or cellulitis of the pinna
and adjacent skin
*Pain in the ear canal and temporomandibular joint region
intensified by jaw motion [4]
Etiological organisms
Infection causes the vast majority of AOE cases. The two
most commonly isolated organisms are Pseudomonas aerugi­
nosa and Staphylococcus aureus.[9] The isolates are polymicro­
bial in a significant number of cases. Other Gram-negative
bacteria are less common. Rare fungal infections have been
described with Aspergillus species and Candida species.[10]
Swabs from the external canal should be interpreted with cau­
INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE, CANADIAN PAEDIATRIC SOCIETY |
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tion because they may reflect normal flora or colonizing or­
ganisms. Swabs should be taken only in unresponsive or se­
vere cases.
Management
The management of AOE has been the subject of one
Cochrane systematic review (updated 2010) [8], one metaanalysis by the American Academy of Otolaryngology-Head
and Neck Surgery (AAO-HNS),[11] and one clinical practice
guideline (AAO-HNS).[4] The Cochrane publication reviewed
19 studies that included 3382 participants. Overall, only
three of the 19 studies were considered to be of high quality
and only two were done in a primary care setting. Similar
findings were reached in the AAO-HNS meta-analysis and are
reflected in the practice guideline.
It is clear that topical antimicrobials are effective in mild-tomoderate AOE. No randomized control trials have been pub­
lished comparing topical to systemic antimicrobials. Topical
antimicrobials increased absolute clinical cure rates of AOE
by 46% and bacteriological cure rates by 61% compared with
placebo.[11] There seemed to be minimal to no difference in
clinical or bacteriological cure rate for the addition of topical
steroids to topical antimicrobials, although the quality of
these studies was poor.[4][12] A systematic review showed that
in a combined total of only 92 patients there was a slight su­
periority of topical steroids compared with topical steroids
and topical antimicrobials for clinical cure at seven to 11 days.
Topical acidifying solutions (eg, Buro-Sol) have also been
shown to be equally effective as topical antimicrobials in clini­
cal cure rates at one week, but inferior in clinical and micro­
biological cure at two to three weeks. Topical antiseptics such
as alcohol, gentian violet, m-Cresyl acetate, thimerosal and
thymol have been shown in small studies to be equally effec­
tive as topical antimicrobials but are not specifically marketed
in Canada for treatment of AOE.
Ototoxic topical agents such as gentamicin or neomycin,
agents with a low pH (including most acidifying and antisep­
tic agents), or Cortisporin (Johnson & Johnson Inc., USA)
topical drops should not be used in the presence of tympanos­
tomy tubes or a perforated tympanic membrane because there
is an increasing body of literature concerning ototoxicity in
both settings.[13] These agents should also not be used if the
tympanic membrane cannot be seen.
For treating mild-to-moderate acute otitis externa, the follow­
ing steps are recommended:
1. First line therapy for mild-to-moderate AOE should be a
topical antibiotic with or without topical steroids for sev­
en to 10 days.[4] More severe cases should be managed
2 | ACUTE OTITIS EXTERNA
with systemic antibiotics that cover S aureus and P aerug­
inosa.
2. Adequate pain control for mild-to-moderate AOE can be
achieved with systemic acetaminophen, non-steroidal an­
ti-inflammatory medications or oral opioid preparations.
Topical steroid preparations have had mixed effects on
hastening pain relief in clinical trials and cannot be rec­
ommended as monotherapy.
3. If the clinician cannot see the ear canal, an expandable
wick can be placed to decrease canal edema and facili­
tate topical medication delivery.[14] Although aural toilet­
ing and wick therapy are common and logical practices,
there have been no randomized controlled trials examin­
ing their effectiveness. Ear candling has been shown to
have no efficacy and can be harmful.[15]
Clinical response should be evident within 48 h to 72 h [16]
but full response can take up to six days in patients treated
with antibiotic and steroid drops.[8] Nonresponse should
prompt an evaluation for obstruction, the presence of a for­
eign body, non-adherence to therapy or an alternative diagno­
sis (eg, dermatitis from contact with nickel, a viral or fungal
infection or antimicrobial resistance).
Malignant otitis externa
In patients who are immunodeficient or who have insulin-de­
pendent diabetes, special measures should be taken to rule
out malignant otitis externa. This invasive infection of the
cartilage and bone of the canal and external ear may present
with facial nerve palsy and pain as a prominent symptom.
Imaging with a computed tomography or magnetic resonance
imaging scan may be needed to confirm the clinical diagnosis.
[17] Aggressive debridement with systemic antibiotics targeted
at P aeruginosa, and in some cases Aspergillus species, is criti­
cal.
Prevention
Targeting typical causal culprits of AOE, such as moisture and
trauma, seems prudent. Some experts recommend simple
techniques for keeping water out of the ears (eg, inserting a
soft, malleable plug into the auricle to block entry to the ear
canal) or removing water from the ears after swimming (by
positioning or shaking the head, or by using a hair dryer on a
low setting). Others advise avoiding cotton swabs because
they might impact cerumen. Daily prophylaxis with alcohol or
acidic drops during at-risk activities has also been suggested
but not studied. Using hard earplugs should be avoided be­
cause they can cause trauma, and the use of custom ear canal
molds and tight swim caps remains controversial.[5]
TABLE 1
Medications available in Canada for acute otitis externa
Brand name
Active ingredients
Dosing and duration as per the product monograph
Polysporin plus pain Polymyxin B sulphate –
lidocaine HCl
relief ear drops*,†
Three to four drops four times/day
Infants and children, two to three drops are suggested.
Solution may be applied by saturating a gauze or cotton wick which may be left in the canal for 24 h to 48 h,
keeping the wick moist by adding a few drops of solution as required.
No duration stated
Polysporin eye/ear
Polymyxin B sulphate –
gramicidin
One to two drops four times/day, or more frequent as required
No duration stated
Polymyxin B sulphate –
neomycin sulphate –
gramicidin
One to two drops two to four times/day for seven days
Neomycin sulphate –
polymyxin B sulfate –
hydrocortisone
Four drops three to four times/day
No duration stated
drops*,†
Neosporin eye and
ear solution*,‡
Cortisporin otic
solution sterile*,†,§
Sofracort*,¶
Framycetin sulfate – grami­ Two to three drops three to four times/day
cidin – dexamethasone
No duration stated
Ciprodex**
Ciprofloxacin HCI –
dexamethasone
Four drops twice/day for seven days
Buro-Sol otic solu­
Aluminum acetate –
benzethonium chloride –
acetic acid
Two to three drops three to four times/day
No duration stated
tion*,§§
Gentamicin – betametha­
sone
Three to four drops three times/day
No duration stated
Garamycin otic
Gentamicin sulfate
Three to four drops three times/day
No duration stated
tion*,††,‡‡
Garasone otic solu­
drops*,‡‡
* Should not be used in patients with a non-intact tympanic membrane; †Johnson & Johnson Inc., USA; ‡GlaxoSmithKline, UK; §sanofi-aventis Canada Inc.; ¶Alcon
Canada Inc.;**Off-label use;†† Stiefel Canada Inc.; ‡‡Merck Canada Inc.; §§Schering Canada Inc.
Acknowledgements
This practice point has been reviewed by the Community Paediatrics
and Drug Therapy and Hazardous Substances Committees of the
Canadian Paediatric Society.
References
1. Wright DN, Alexander JM. Effect of water on the bacterial flo­
ra of swimmer’s ears. Arch Otolaryngol 1974;99(1):15-8.
2. Rowshan HH, Keith K, Baur D, Skidmore P. Pseudomonas
aeruginosa infection of the auricular cartilage caused by "high
ear piercing": A case report and review of the literature. J Oral
Maxillofac Surg 2008;66(3):543-6.
3. Keene WE, Markum AC, Samadpour M. Outbreak of
Pseudomonas aeruginosa infections caused by commercial
piercing of upper ear cartilage. JAMA 2004 25;291(8):981-5.
4. Rosenfeld RM, Brown L; American Academy of Otolaryngolo­
gy--Head and Neck Surgery Foundation, et al. Clinical practice
guideline: Acute otitis externa. Otolaryngol Head Neck Surg
2006;134(4 Suppl): S4-23.
5. Osguthorpe JD, Nielsen DR. Otitis externa: Review and clini­
cal update. Am Fam Physician 2006;74(9):1510-6.
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6. McKean SA, Hussain SSM. Otitis externa. Clinical Otolaryn­
gology 2007;32(6):457-9.
7. Stone KE, Serwint JR. Otitis externa. Pediatr Rev 2007;28(2):
77-8.
8. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis ex­
terna. Cochrane Database Syst Rev 2010:1: CD004740.
9. Roland PS, Stroman DW. Microbiology of acute otitis externa.
Laryngoscope 2002;112(7):1166-77.
10. Martin TJ, Kerschner JE, Flanary VA. Fungal causes of otitis ex­
terna and tympanostomy tube otorrhea. Int J Pediatr Otorhino­
laryngol 2005;69(11):1503-8.
11. Rosenfeld RM, Singer M, Wasserman JM, Stinnett SS. System­
atic review of topical antimicrobial therapy for acute otitis exter­
na. Otolaryngol Head Neck Surg 2006;134(4 Suppl):S24-48.
12. Mösges R, Domröse CM, Löffler J. Topical treatment of acute
otitis externa: Clinical comparisonof an antibiotics ointment
alone or in combination with hydrocortisone acetate. Eur Arch
Otorhinolaryngol 2007;264(9):1087-94.
13. Stockwell, M. Gentamicin ear drops and ototoxicity: Update
CMAJ 2001;164(1):93-4.
14. Otitis externa. In Cummings CW, Flint PW, Haughey BH, et
al. Otolaryngology: Head and Neck Surgery, 4th edn. Philadel­
phia, PA: Mosby, 2005.
15. Seely DR, Quigley SM, Langman AW. Ear candles: Efficacy and
safety. Laryngoscope 1996;106(10):1226–9.
16. van Balen FA, Smit WM, Zuithoff NP, Verheij TJ. Clinical effi­
cacy of three common treatments in acute otitis externa in pri­
mary care: Randomised controlled trial. BMJ 2003;327(7425):
1201-5.
17. Rubin Grandis J, Branstetter BF 4th, Yu VL. The changing face
of malignant (necrotizing) external otitis: Clinical, radiological,
and anatomic correlations. Lancet Infect Dis 2004;4(1):34-9.
CPS
D
AND IMMUNIZATION COMMITTEE
INFECTIOUS
I
Members: Robert Bortolussi MD; Natalie A Bridger MD; Jane C
Finlay MD; Susanna Martin MD (Board Representative); Jane C McDonald MD; Heather Onyett MD; Joan Louise Robinson MD
(Chair)
Liaisons: Upton D Allen MD, Canadian Pediatric AIDS Research
Group; Michael Brady MD, Committee on Infectious Diseases,
American Academy of Pediatrics; Janet Dollin MD, College of Family Physicians of Canada; Charles PS Hui MD, Committee to Advise
on Tropical Medicine and Travel, Public Health Agency of Canada;
Nicole Le Saux MD, Immunization Monitoring Program, ACTive
(IMPACT); Dorothy L Moore MD, National Advisory Committee
on Immunization (NACI); John S Spika MD, Public Health Agency
of Canada
C
sultant: Noni E MacDonald MD
Princi pal author: Charles PS Hui MD
on-
Also available at www.cps.ca/en
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OTITIS
EXTERNA
Disclaimer: The recommendations in this position statement do not indicate an
exclusive course of treatment or procedure to be followed. Variations, taking in­
to account individual circumstances, may be appropriate. Internet addresses
are current at time of publication.