Review

Managing otitis externa

Karen Koch, MBChB
Medical Writer and Content Specialist, Mediscribe

Correspondence to: Karen Koch, e-mail: karenk@vodamail.co.za

Keywords: otitis externa, otologicals, ear infections

Abstract
Otitis externa is a common ear inflammatory condition, usually caused by infection, and affecting up to 10% of the population. It is
especially common in children, and is more likely to occur in those who are frequently exposed to water. Cleaning the affected area,
the application of topical agents and prevention are the cornerstones of treatment. This article will review the different types of otitis
externa and treatment options.
© Medpharm S Afr Pharm J 2012;79(8):17-22

Introduction • Any trauma, such as that resulting from excessive cleaning or

aggressive scratching of the ear canal. This creates abrasions
External otitis, also known as otitis externa or swimmer’s ear, is a along the thin layer of skin in the ear canal, allowing organisms
condition in which there is inflammation of the external auditory to gain access to the deeper tissue.
canal. It can be caused by a number of factors, including infectious,
• Devices that occlude the ear canal, such as hearing aids,
allergic and dermatological disease. Acute bacterial infection is earphones, or diving caps.
the most common cause of external otitis.1
• Allergic contact dermatitis, which is usually caused by ototopical
External otitis can occur in all age groups. An estimated 10%
2 medication, e.g. neomycin, benzocaine, and propylene glycol,7,8
of people develop external otitis during their lifetime. External as well as cosmetics or shampoos. These are Gell and Coombs
otitis is more common in children, and peaks in the10- to 14-year type IV delayed hypersensitivity reactions. Secondary exposure
to the allergen initiates an inflammatory response.
age group.3 Usually, it occurs in summer, rather than winter, due
to increased participation in outdoor water activities, when it is • Dermatological conditions, e.g. psoriasis and atopic dermatitis.
warmer.2 Once the breakdown in natural defences occurs, pathogenic
organisms such as Pseudomonas aeruginosa (38%), Staphylococcus
Mechanism of otitis externa epidermidis (9%) and S. aureus (8%) replace the natural flora.9

The ear canal is designed to combat foreign particles and infection. Other organisms which can cause infection include anaerobic
The outer cartilaginous portion is lined with hair follicles and pathogens (4-25%), such as Bacteroides and peptostreptococci,
cerumen glands. The lining of the ear canal undergoes continual and fungal infection (2-10%).4-6,9-12
sloughing of cells, the migration of which allows removal of keratin
debris and cerumen. Cerumen maintains an acidic environment Signs and symptoms
in the external ear canal, and its sticky nature traps particles, Pruritis, ear pain, discharge, and hearing loss are the most
preventing penetration deeper into the ear. common symptoms of otitis externa.2 The ear may be tender
A breakdown of the skin-cerumen barrier is the first step in the on examination and on otoscopy, usually the external ear canal
appears to be oedematous and erythematous. If present, the ear
pathogenesis of external otitis. This can be caused by:4-6
discharge may be white, yellow, brown, or grey. Severe disease may
• Water exposure from swimming. Excess moisture leads to result in intense pain, periauricular erythema, lymphadenopathy,
skin maceration and breakdown of the skin-cerumen barrier, and fever.6
changing the microflora of the ear canal to predominantly Generally, fungal infections cause ear itching, discomfort,
Gram-negative bacteria. discharge, and a feeling that something is in the ear canal, whereas
pain is more intense in patients with bacterial infections.13

S Afr Pharm J 17 2012 Vol 79 No 8

 Review

Contact dermatitis also frequently causes pruritis. This is the penetration of ear drops into the site of inflammation.15 Ear-canal
dominant symptom. A lack of response to external otitis treatment cleaning should be performed through an otoscope that allows
over a one-week period can indicate contact dermatitis.14 direct visualisation and use of a cotton swab to gently remove
debris and cerumen. The ear canal may be irrigated with a 1:1
Complications dilution of 3% hydrogen peroxide at body temperature.16

Left untreated, external otitis can lead to periauricular cellulitis

and malignant external otitis.  Malignant external otitis, also Topical therapy
known as necrotising external otitis, is a severe, potentially fatal Topical therapy is highly effective in treating external otitis, and
complication of acute bacterial external otitis. It is most common delivers a high concentration of medication to the infected and
in elderly diabetic patients or other immunocompromised inflamed tissue, with minimal side-effects.15,17 Several topical
individuals, and occurs when the infection spreads from the skin
agents are available to treat external otitis, including antibiotics,
to the bone and bone marrow spaces of the skull base. It also
antiseptics, glucocorticoids, and acidifying solutions.1,2 They are
affects the soft tissue and cartilage of the temporal region. 14
administered as single agents and combination formulas. Most
are used in a liquid form, although ointments and powders are
Treatment also available.
Usually, treatment of external otitis is topical drug therapy, rather Table I lists the available ototopical agents in South Africa.
than oral antibiotics or surgery, as the disease is limited to the skin
of the ear canal. Antiseptics

Systemic antibiotics are indicated in patients with deep tissue Antiseptics function as bacteriostatic agents, not as bacteriocidal
infection (outside the external canal) and immunocompromised agents, like antibiotics. They are also effective against fungal
hosts. infections. Their precise mechanism of action is not fully
understood, but they make the ear canal less habitable for bacteria
Cleaning the external canal (aural toilet) and fungi, and may loosen debris in the ear canal. Systemic reviews
and meta-analyses suggest that these agents are as effective as
Cleaning out the external canal is the first step in treatment. The
other topical agents.15,17 Available antiseptics are listed in Table I.
removal of cerumen, desquamated skin, and purulent material
from the ear canal greatly facilitates healing, and enhances

Table I: Available ototopical agents in South Africa18

Type of agents Active agents Brand names

Antiseptic agents Thiomersal Merthiolate®

Phenazone Aurone®

Acidifying agents Acetic acid After Swim Ear Drops®, Dischem Swimmer’s Ear Cleanser®

Corticosteroids Betamethasone Betnesol®

Hydrocortisone Dilucort®, Skin calm®, Mylocort®, Procutan®

Dexamethasone Maxidex®

Corticosteroids plus antibiotics Hydrocortisone plus ciprofloxacin Ciprobay HC Otic®

Dexamethasone plus ciprofloxacin Cilodex®

Dexamethasone plus chloramphenicol plus neomycin Covomycin-D®

Betamethasone plus neomycin Betnesol-N®

Hydrocortisone plus polymyxin B Otosporin®

Hydrocortisone plus polymyxin B plus tetracycline Terra-Cortril®

Corticosteroids plus antiseptics Flumethasone plus clioquinol Locacortem-Vioform®

Dexamethasone plus framycetin Sofradex®

Antiseptics plus analgesics Phenazone plus benzocaine Adco-Otised®

Phenazone plus Na-sulphacetamide plus benzocaine Covancaine®

S Afr Pharm J 18 2012 Vol 79 No 8

 Review

Acidifying solutions

The most common otitis externa pathogens, P. aeruginosa and

S. aureus, grow well in mildly acidic environments (pH of 6-7),
but grow less well at a lower pH.19 Thus, simply acidifying the ear
canal inhibits bacterial growth. Acidifying agents help reacidify
the ear canal, dry weeping lesions, and debride crust in contact
dermatitis.16 The most commonly used acidifying solutions
are acetic, boric, hydrochloric and sulphuric acids. Acidifying
solutions are generally safe, but may be associated with local
irritation, manifested by burning or stinging. In the presence of
tympanic membrane perforation, acidifying solutions can be
particularly irritating to the mucosa of the middle ear. Available
acidifying solutions are listed in Table I.

Antibiotics 

Topical antibiotics are highly effective in treating external

otitis.20 One systematic review found that topical antibiotics
increased absolute clinical cure rate, compared to placebo,
by 46% [95% confidence interval (CI) 29-63%]. The review
also found no significant difference when comparing topical
antibiotics to antiseptics, or to combination antibiotic plus
glucocorticoid preparations. There was also no difference in
cure rates between quinolone and nonquinolone antibiotics.17

The ideal antibiotic regimen should have specific coverage

against the most common pathogens, P. aeruginosa and S.
aureus. The fluoroquinolones (ofloxacin and ciprofloxacin),
polymyxin B (a polypeptide-type antimicrobial), and the
aminoglycosides, neomycin, tobramycin and gentamycin, are
all effective against these pathogens.21,22

Side-effects, such as ototoxicity with aminoglycoside agents,

particularly where the tympanic membrane is perforated, are of

11308
concern.23 Allergic contact dermatitis is commonly associated
with neomycin when used for prolonged courses.24 Antibiotic
resistance, particularly against P. aeruginosa with chronic use
of ototopical fluoroquinolones, is also of concern.25 Topical
antibiotics are only available in combination with glucorticoids
in South Africa (see Table I). Murine® Clear Eyes eye drops Murine® Moisture Eyes eye drops
For the removal of redness Relieves dry, scratchy eyes
Antifungal agents caused by minor irritations such as by moisturising and soothing
adverse conditions and eye-strain. irritated eyes.

Topical antifungals are considered to be the first-line treatment

of fungal external otitis. Clotrimazole has the greatest zone of
inhibition for common fungi. Clotrimazole and miconazole also
have antibacterial effects against S. aureus, but not against P.
aeruginosa. Some antifungals are available in liquid form, and
S2 H1176 (Act 101/1965) Each 1 ml MURINE® CLEAR EYES contains: Naphazoline hydrochloride
others only as a cream or ointment that is either injected into 0,12 mg, Boric acid 17,7 mg, Sodium borate 0,36 mg, Hypromellose 1,5 mg. Preservatives:
Disodium edetate 0,1 %, Benzalkonium chloride 0,01 %.
the ear canal or swabbed in the lateral ear canal and allowed to
melt down.26,27

Glucocorticoids Applicant: Pharmacare Ltd. Co. Reg. No.: 1898/000252/06, Building 12,
Healthcare Park, Woodlands Drive, Woodmead, 2191. A15025 08/12

Topical glucocorticoids decrease inflammation, resulting in

relief of pruritus and decreased pain. Glucocorticoids that
are used to treat external otitis include hydrocortisone,
dexamethasone and prednisolone. A meta-analysis of

S Afr Pharm J 19 2012 Vol 79 No 8

 Review

randomised trials, which included three studies comparing an are made of compressed cotton. They expand as the ototopical
antimicrobial plus glucocorticoid vs. an antimicrobial alone, found medicine is applied. The wick allows topical medications to reach
comparable clinical and bacteriological cure rates at seven days the medial aspect of the ear canal. They also facilitate longer
for regimens with and without glucocorticoids. The use of topical retention of topical solutions in the affected areas. Wicks should
glucocorticoids decreased time to symptom resolution by one be replaced every one to three days if significant swelling persists.
day.16 Glucocorticoids are the agents of choice when otitis externa Wicks can be removed once ear canal swelling subsides. Wick
is caused by contact dermatitis, but doesn’t respond to acidifying placement usually requires referral to an otorhinolaryngologist.16
treatment.16 Available glucocorticoids are listed in Table I.

Combination therapy  Oral agents

Several combinations of topical agents are available in clinical The addition of an oral antibiotic to topical antibiotic therapy does
practice. The efficacy of several different combination preparations not appear to enhance treatment in uncomplicated external otitis.
has been examined in meta-analyses of randomised trials, with no Systemic antibiotics, in addition to topical antibiotics, are indicated
specific combination therapy appearing as superior over other with deeper tissue infection, due to lack of adequate penetration
therapy.15 Available combination therapies are listed in Table I. with topical therapy. Combined systemic and topical antibiotics
are also indicated in patients who are immunosuppressed, i.e.
Choice of topical agent post-transplant, and those receiving chemotherapy or radiation
Choosing the correct ototopical agent, or combination of agents, therapy, or where there is a high risk of malignant external otitis.16
is difficult. The choice of agent depends on the type and severity Antibiotics need to be effective against the most common
of otitis externa.15 pathogens, P. aeruginosa and S. aureus. Quinolones (ciprofloxacin
• Mild external otitis (bacterial, fungal and contact dermatitis): A or ofloxacin) usually provide necessary coverage.28 Ciprofloxacin
topical preparation containing an antiseptic and analgesic, or can be given at a dose of 500 mg twice daily, for seven to 10 days.16
antiseptic and glucocorticoid (see Table I), is recommended.
Antibiotics and antifungal agents may cause potential side- Pain control
effects, and do not warrant use in mild cases.16
Pain from otitis externa can be mild to severe. Mild-to-moderate
• Moderate and severe disease (bacterial and fungal): A topical pain will respond to topical therapy. Many antiseptic plus analgesic
preparation that contains an antibiotic, an antiseptic and a combinations are available in South Africa (see Table I). Patients
glucocorticoid is recommended. Where a fungal infection is
with severe pain may require paracetamol, an oral nonsteroidal
suspected, topical antifungal creams and ointments would need
anti-inflammatory agent (NSAID) or, in particularly severe cases,
to be used. The antibiotic should have good coverage against
opioid analgesics. Care should be exercised to ensure that pain
S. aureus and P. aeruginosa. The antifungal agents, clotrimazole
medications do not mask an inadequately treated case.16
and miconazole, are recommended to treat fungal infections.16

Instillation and duration of therapy  Prevention

Proper instillation of ear drops entails tilting the head towards Several factors can help in the recovery from, and prevention of,
the opposite shoulder, pulling the superior aspect of the auricle otitis externa:
upward, and filling the ear canal with drops. The person should lie
on his or her side for 20 minutes, or place a cotton ball in the ear • Avoid trauma to the external ear canal: The use of earbuds, or
canal for 20 minutes, to maximise medicine exposure. cleaning ears with fingers, should be avoided. The ear canal is
self-cleaning, and any foreign object can cause damage to the
Most topical preparations should be given three to four times epithelium, resulting in otitis externa.16
daily. Topical fluoroquinolones can be given two times daily.
• Avoid exposing the external ear canal to water: The ear should
The course of treatment varies. The initial treatment course is be protected from water during recovery from external otitis,
usually seven days, with follow-up. Further treatment may be and in patients who experience frequent bouts. This can be
continued for up to two weeks. Patients with symptoms that accomplished by placing a cotton ball, coated with petroleum
persist beyond two weeks should be re-evaluated for treatment jelly, in the ear canal, while bathing. Those with active external
failure.16 otitis should not swim, and ideally, should refrain from water
sports for seven to ten days. Competitive swimmers should
Wick placement
be encouraged to use well-fitting ear plugs. Hearing aids and
Direct application of topical agents to the infected site is a key ear phones should not be worn until pain and discharge have
element in the treatment of external otitis, regardless of severity. subsided. If there is exposure to water, active drying methods,
Those with severe disease (i.e. a completely occluded canal) should such as shaking the ear of excess water, and gently blow drying
also have a wick placed. Wicks are commercially available, and the ear, can help avoid recurrent infections.29

S Afr Pharm J 20 2012 Vol 79 No 8

 Review

• Prophylaxis: Prevention should be considered in patients 1993;107(10):898-891. c2012. Cambridge Journals [homepage on the Internet]. c2012. Avail-
able from: http://journals.cambridge.org/action/displayAbstract;jsessionid=BDEF7655C5205
with recurrent external otitis, particularly swimmers,
B8503D26BE769FD0D4D.journals?fromPage=online&aid=1080396
immunocompromised hosts, and in those with a systemic
5. Van Asperen IA, de Rover CM, Schijven J. Risk of otitis externa after swimming in recreational
dermatological condition that affects the ear. Drops containing fresh water lakes containing Pseudomonas aeruginosa. BMJ. 1995;311(7107):1407-1410.
alcohol and acetic acid  help to dry the ear, prevent skin 6. Osguthorpe JD, Nielsen DR. Otitis externa: Review and clinical update. Am Fam Physician.
maceration, and reacidify the ear canal. Hearing aids should be 2006;74(9):1510-1516. American Family Physician [homepage on the Internet]. c2012. Avail-
removed nightly, and regularly cleaned.16 able from: http://www.aafp.org/afp/2006/1101/p1510.html
7. Gehrig KA, Warshaw EM. Allergic contact dermatitis to topical antibiotics: epidemiology,
responsible allergens, and management. J Am Acad Dermatol. 2008; 58(1):1-21. Mendeley
Treatment course and recovery [homepage on the Internet]. c2012. Available from: http://www.mendeley.com/research/
allergic-contact-dermatitis-topical-antibiotics-epidemiology-responsible-allergens-manage-
Some symptom improvement should occur within 36-48 hours ment/
after treatment is initiated, and full symptom resolution by six 8. Sood S, Strachan DR, Tsikoudas A, Stables GI. Allergic otitis externa. Clin Otolaryngol Allied Sci.
days.15 Patients who do not respond to treatment should be 2002;27(4):233-236. Wiley Online Library [homepage on the Internet]. c2012. Available from:
http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2273.2002.00584.x/abstract
referred to an otorhinolaryngologist for further evaluation.
9. Roland PS, Stroman DW. Microbiology of acute otitis externa. Laryngoscope. 2002;112(7 Pt
References 1):1166-1177. Wiley Online Library [homepage on the Internet]. c2012. Available from: http://
onlinelibrary.wiley.com/doi/10.1097/00005537-200207000-00005/abstract
1. Stone KE. Otitis externa. Pediatr Rev. 2007;28(2):77. Pediatrics in Review [homepage on the 10. Stroman DW, Roland PS, Dohar J, Burt W. Microbiology of normal external auditory canal. La-
Internet]. c2012. Available from: http://pedsinreview.aappublications.org/content/28/2/77. ryngoscope. 2001;111(11 Pt 1):2054-2059. Wiley Online Library [homepage on the Internet].
extract c2012. Available from: http://onlinelibrary.wiley.com/doi/10.1097/00005537-200111000-
2. Beers SL, Abramo TJ. Otitis externa review. Pediatr Emerg Care. 2004;20(4):250-256. Pediatric 00035/abstract
Emergency Care [homepage on the Internet]. c2012. Available from: http://journals.lww.com/ 11. Brook I, Frazier EH, Thompson DH. Aerobic and anaerobic microbiology of external otitis. Clin
pec-online/Citation/2004/04000/Otitis_Externa_Review.9.aspx Infect Dis. 1992;15(6):955. JSTOR [homepage on the Internet]. c2012. Available from: http://
3. Estimated burden of acute otitis externa: United States, 2003-2007. MMWR Morb Mortal Wkly www.jstor.org/discover/10.2307/4456799?uid=3739368&uid=2129&uid=2&uid=70&uid=4&
Rep. 2011;60(19):605. Centers for Disease Control and Prevention [homepage on the Internet]. sid=21100749102031
c2012. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a2.htm 12. Clark WB, Brook I, Bianki D, Thompson DH. Microbiology of otitis externa. Otolaryngol Head
4. Russell JD, Donnelly M, McShane DP, et al. What causes acute otitis externa? J Laryngol Otol. Neck Surg. 1997;116(1):23-25. ScienceDirect.com [homepage on the Internet]. c2012. Avail-

S Afr Pharm J 21 2012 Vol 79 No 8

 Review
able from: www.sciencedirect.com/science/article/pii/S0194599897703462 on the Internet]. c2012. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9366699
13. Ho T, Vrabec JT, Yoo D, Coker NJ. Otomycosis: clinical features and treatment implica- 22. Schwartz RH. Once-daily ofloxacin otic solution versus neomycin sulfate/polymyxin B sulfate/
tions. Otolaryngol Head Neck Surg. 2006;135(5):787-791. ScienceDirect.com [homepage hydrocortisone otic suspension four times a day: a multicenter, randomized, evaluator-blind-
on the Internet]. c2012. Available from: http://www.sciencedirect.com/science/article/pii/ ed trial to compare the efficacy, safety, and pain relief in pediatric patients with otitis externa.
S0194599806027926 Curr Med Res Opin. 2006;22(9):1725-1736.
14. Goguen LA. External otitis: Pathogenesis, clinical features, and diagnosis. UpToDate [home- 23. Roland PS, Stewart MG, Hannley M, et al. Consensus panel on role of potentially ototoxic an-
page on the Internet]. c2012. Available from: http://www.uptodate.com/contents/external- tibiotics for topical middle ear use: introduction, methodology, and recommendations. Oto-
otitis-pathogenesis-clinical-features-and-diagnosis laryngol Head Neck Surg. 2004;130(3 Suppl):S51-S56. Pediatrics [homepage on the Internet].
15. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. [Cochrane review]. In: The c2012. Available from: http://pediatrics.aappublications.org/content/118/3/e561.full
Cochrane Library, Issue 1, 2010. Oxford: Update Software. 24. Van Ginkel CJ, Bruintjes TD, Huizing EH. Allergy due to topical medications in chronic otitis
16. Goguen, LA. External otitis: Treatment. UpToDate [homepage on the Internet]. c2012. Avail- externa and chronic otitis media. Clin Otolaryngol Allied Sci. 1995;20(4):326-328. Wiley Online
able from: http://www.uptodate.com/contents/external-otitis-treatment Library [homepage on the Internet]. c2012. Available from: http://onlinelibrary.wiley.com/
doi/10.1111/j.1365-2273.1995.tb00052.x/abstract
17. Rosenfeld RM, Singer M, Wasserman JM, Stinnett SS. Systematic review of topical antimicro-
bial therapy for acute otitis externa. Otolaryngol Head Neck Surg. 2006;134(4 Suppl):S24-S48. 25. Dohar JE, Kenna MA, Wadowsky RM. In vitro susceptibility of aural isolates of Pseudomonas
Sage journals [homepage on the Internet]. c2012. Available from: http://oto.sagepub.com/ aeruginosa to commonly used ototopical antibiotics. Am J Otol. 1996;17(2):207-209. Pub-
content/134/4_suppl/S24.abstract Med [homepage on the Internet]. c2012. Available from: http://www.ncbi.nlm.nih.gov/pub-
med/8723948
18. South African Medicines Formulary. 8th ed. Cape Town: Health and Medical Publishing Group;
2008. 26. Vennewald I, Klemm E. Otomycosis: diagnosis and treatment. Clin Dermatol. 2010;28(2):202-
211.
19. Kim JK, Cho JH. Change of external auditory canal pH in acute otitis externa. Ann Otol Rhinol
Laryngol. 2009;118(11):769-772. PubMed [homepage on the Internet]. c2012. Available from: 27. Munguia R, Daniel SJ. Ototopical antifungals and otomycosis: a review. Int J Pediatr Otorhi-
http://www.ncbi.nlm.nih.gov/pubmed/19999361 nolaryngol. 2008;72(4):453-459.
20. Rosenfeld RM, Brown L, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Oto- 28. Santos F, Selesnick SH, Gurnstein E. Diseases of the external ear. In: Lalwani AK, editor. Current
laryngol Head Neck Surg. 2006;134(4 Suppl):S4-S23. Otolaryngology - Head and Neck Surgery diagnosis and treatment in otolaryngology: head and neck surgery. New York: Lange Medical
[homepage on the Internet]. c2012. Available from: http://www.entnet.org/Practice/upload/ Books/McGraw-Hill; 2004.
AOE-cpg.pdf 29. Osguthorpe JD, Nielsen DR. Otitis externa: review and clinical update. Am Fam Physician.
21. Jones RN, Milazzo J, Seidlin M. Ofloxacin otic solution for treatment of otitis externa in children 2006;74(9):1510-1516. ScienceDirect.com [homepage on the Internet]. c2012. Available from:
and adults. Arch Otolaryngol Head Neck Surg.1997;123(11):1193-1200. PubMed [homepage http://www.sciencedirect.com/science/article/pii/S0738081X09002454

S Afr Pharm J 22 2012 Vol 79 No 8