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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
Introduction
External otitis, also known as otitis externa or swimmers ear, is a
condition in which there is inflammation of the external auditory
canal. It can be caused by a number of factors, including infectious,
allergic and dermatological disease. Acute bacterial infection is
the most common cause of external otitis.1
External otitis can occur in all age groups. An estimated 10%
of people develop external otitis during their lifetime. External
otitis is more common in children, and peaks in the10- to 14-year
age group.3 Usually, it occurs in summer, rather than winter, due
to increased participation in outdoor water activities, when it is
warmer.2
2
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Contact dermatitis also frequently causes pruritis. This is the
dominant symptom. A lack of response to external otitis treatment
over a one-week period can indicate contact dermatitis.14
Complications
Left untreated, external otitis can lead to periauricular cellulitis
and malignant external otitis. Malignant external otitis, also
known as necrotising external otitis, is a severe, potentially fatal
complication of acute bacterial external otitis. It is most common
in elderly diabetic patients or other immunocompromised
individuals, and occurs when the infection spreads from the skin
to the bone and bone marrow spaces of the skull base. It also
affects the soft tissue and cartilage of the temporal region. 14
Topical therapy
Topical therapy is highly effective in treating external otitis, and
delivers a high concentration of medication to the infected and
inflamed tissue, with minimal side-effects.15,17 Several topical
agents are available to treat external otitis, including antibiotics,
antiseptics, glucocorticoids, and acidifying solutions.1,2 They are
administered as single agents and combination formulas. Most
are used in a liquid form, although ointments and powders are
also available.
Treatment
Usually, treatment of external otitis is topical drug therapy, rather
than oral antibiotics or surgery, as the disease is limited to the skin
of the ear canal.
Antiseptics
Active agents
Brand names
Antiseptic agents
Thiomersal
Merthiolate
Phenazone
Aurone
Acidifying agents
Acetic acid
Corticosteroids
Betamethasone
Betnesol
Hydrocortisone
Dexamethasone
Maxidex
Ciprobay HC Otic
Cilodex
Covomycin-D
Betnesol-N
Otosporin
Terra-Cortril
Locacortem-Vioform
Sofradex
Adco-Otised
Covancaine
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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
11308
Antifungal agents
Topical antifungals are considered to be the first-line treatment
of fungal external otitis.Clotrimazolehas the greatest zone of
inhibition for common fungi. Clotrimazole andmiconazolealso
have antibacterial effects against S. aureus, but not against P.
aeruginosa. Some antifungals are available in liquid form, and
others only as a cream or ointment that is either injected into
the ear canal or swabbed in the lateral ear canal and allowed to
melt down.26,27
S2 H1176 (Act 101/1965) Each 1 ml MURINE CLEAR EYES contains: Naphazoline hydrochloride
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 %.
Glucocorticoids
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randomised trials, which included three studies comparing an
antimicrobial plus glucocorticoid vs. an antimicrobial alone, found
comparable clinical and bacteriological cure rates at seven days
for regimens with and without glucocorticoids. The use of topical
glucocorticoids decreased time to symptom resolution by one
day.16 Glucocorticoids are the agents of choice when otitis externa
is caused by contact dermatitis, but doesnt respond to acidifying
treatment.16 Available glucocorticoids are listed in Table I.
Combination therapy
Oral agents
Pain control
Pain from otitis externa can be mild to severe. Mild-to-moderate
pain will respond to topical therapy. Many antiseptic plus analgesic
combinations are available in South Africa (see Table I). Patients
with severe pain may require paracetamol, an oral nonsteroidal
anti-inflammatory agent (NSAID) or, in particularly severe cases,
opioid analgesics. Care should be exercised to ensure that pain
medications do not mask an inadequately treated case.16
Prevention
Several factors can help in the recovery from, and prevention of,
otitis externa:
Avoid trauma to the external ear canal: The use of earbuds, or
cleaning ears with fingers, should be avoided. The ear canal is
self-cleaning, and any foreign object can cause damage to the
epithelium, resulting in otitis externa.16
Avoid exposing the external ear canal to water: The ear should
be protected from water during recovery from external otitis,
and in patients who experience frequent bouts. This can be
accomplished by placing a cotton ball, coated with petroleum
jelly, in the ear canal, while bathing. Those with active external
otitis should not swim, and ideally, should refrain from water
sports for seven to ten days. Competitive swimmers should
be encouraged to use well-fitting ear plugs. Hearing aids and
ear phones should not be worn until pain and discharge have
subsided. If there is exposure to water, active drying methods,
such as shaking the ear of excess water, and gently blow drying
the ear, can help avoid recurrent infections.29
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Prophylaxis: Prevention should be considered in patients
with recurrent external otitis, particularly swimmers,
immunocompromised hosts, and in those with a systemic
dermatological condition that affects the ear. Drops containing
alcohol and acetic acid help to dry the ear, prevent skin
maceration, and reacidify the ear canal. Hearing aids should be
removed nightly, and regularly cleaned.16
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