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

Elements to consider in the diagnosis of diffuse acute otitis

externa:

Abstract

Acute otitis externa, also known as swimmers ear, is a common disease of children, adolescents and adults. While chronic suppurative otitis media or acute otitis media with tympanostomy 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 externa, without acute otitis media, tympanostomy tubes or a perforation being present.

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

Key Words: Acute otitis externa; Swimmers ear

WITH OR WITHOUT hearing loss or jaw pain*

Acute otitis externa (AOE), also known as swimmers ear, is
a common disease of children, adolescents and adults. It is
defined by diffuse inflammation of the external ear canal. Primarily a disease of children over two years of age, it is commonly associated with swimming. Local defence mechanisms
become impaired by prolonged ear canal wetness. Skin
desquamation leads to microscopic fissures that provide a
portal of entry for infecting organisms.[1] Other risk factors
for AOE include: trauma, a foreign body in the ear, using a
hearing 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 discharge from their ear canal. A distinguishing sign of AOE
from acute otitis media with otorrhea is the finding of tenderness of the tragus when pushed and of the pinna when pulled
in AOE. These signs are classically described as out of proportion to the degree of inflammation observed. On direct otoscopy, the canal is edematous and erythematous and may be
associated with surrounding cellulitis.[4] There may be cellulitis or chondritis of the pinna.

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 aeruginosa and Staphylococcus aureus.[9] The isolates are polymicrobial 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
caution because they may reflect normal flora or colonizing
organisms. Swabs should be taken only in unresponsive or severe cases.

INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE, CANADIAN PAEDIATRIC SOCIETY |

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 published 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 superiority 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
clinical cure rates at one week, but inferior in clinical and microbiological 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 effective 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 antiseptic agents), or Cortisporin (Johnson & Johnson Inc., USA)
topical drops should not be used in the presence of tympanostomy 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 following steps are recommended:
1. First line therapy for mild-to-moderate AOE should be a
topical antibiotic with or without topical steroids for seven to 10 days.[4] More severe cases should be managed
with systemic antibiotics that cover S aureus and P aeruginosa.

2 | ACUTE OTITIS EXTERNA

2. Adequate pain control for mild-to-moderate AOE can

be achieved with systemic acetaminophen, non-steroidal
anti-inflammatory medications or oral opioid preparations. Topical steroid preparations have had mixed effects on hastening pain relief in clinical trials and cannot be recommended as monotherapy.
3. If the clinician cannot see the ear canal, an expandable
wick can be placed to decrease canal edema and facilitate topical medication delivery.[14] Although aural toileting and wick therapy are common and logical practices,
there have been no randomized controlled trials examining 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 foreign body, non-adherence to therapy or an alternative diagnosis (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-dependent 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 critical.

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
because 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 betamethasone

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 flora of swimmers 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 Otolaryngology--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 clinical update. Am Fam Physician 2006;74(9):1510-6.
6. McKean SA, Hussain SSM. Otitis externa. Clinical Otolaryngology 2007;32(6):457-9.
7. Stone KE, Serwint JR. Otitis externa. Pediatr Rev 2007;28(2):
77-8.

INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE, CANADIAN PAEDIATRIC SOCIETY |

8. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. 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 externa and tympanostomy tube otorrhea. Int J Pediatr Otorhinolaryngol 2005;69(11):1503-8.
11. Rosenfeld RM, Singer M, Wasserman JM, Stinnett SS. Systematic review of topical antimicrobial therapy for acute otitis externa. Otolaryngol Head Neck Surg 2006;134(4 Suppl):S24-48.
12. Msges R, Domrse CM, Lffler 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. Philadelphia, PA: Mosby, 2005.
15. Seely DR, Quigley SM, Langman AW. Ear candles: Efficacy
and safety. Laryngoscope 1996;106(10):12269.

16. van Balen FA, Smit WM, Zuithoff NP, Verheij TJ. Clinical efficacy of three common treatments in acute otitis externa in primary 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 INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE
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
Consultant: Noni E MacDonald MD
Principal author: Charles PS Hui MD

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 into account individual circumstances, may be appropriate. Internet addresses
are current at time of publication.