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

External otitis, also known as otitis externa or swimmer’s 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%
2 medication, e.g. neomycin, benzocaine, and propylene glycol,7,8
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
Mechanism of otitis externa
aggressive scratching of the ear canal. This creates abrasions
along the thin layer of skin in the ear canal, allowing organisms
to gain access to the deeper tissue.
• Devices that occlude the ear canal, such as hearing aids,
earphones, or diving caps.
• Allergic contact dermatitis, which is usually caused by ototopical
as well as cosmetics or shampoos. These are Gell and Coombs
type IV delayed hypersensitivity reactions. Secondary exposure
to the allergen initiates an inflammatory response.
• Dermatological conditions, e.g. psoriasis and atopic dermatitis.
Once the breakdown in natural defences occurs, pathogenic
organisms such as Pseudomonas aeruginosa (38%), Staphylococcus
epidermidis (9%) and S. aureus (8%) replace the natural flora.9

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

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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
penetration of ear drops into the site of inflammation.15 Ear-canal
cleaning should be performed through an otoscope that allows
direct visualisation and use of a cotton swab to gently remove
debris and cerumen. The ear canal may be irrigated with a 1:1
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
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
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.
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.
Table I lists the available ototopical agents in South Africa.
Antiseptics

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

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®

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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

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

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 Review
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 doesn’t respond to acidifying
treatment.16 Available glucocorticoids are listed in Table I.
Combination therapy  Oral agents
Several combinations of topical agents are available in clinical
practice. The efficacy of several different combination preparations
has been examined in meta-analyses of randomised trials, with no
specific combination therapy appearing as superior over other
therapy.15 Available combination therapies are listed in Table I.
Choice of topical agent
Choosing the correct ototopical agent, or combination of agents,
is difficult. The choice of agent depends on the type and severity
of otitis externa.15
• Mild external otitis (bacterial, fungal and contact dermatitis): A
topical preparation containing an antiseptic and analgesic, or
antiseptic and glucocorticoid (see Table I), is recommended.
Antibiotics and antifungal agents may cause potential side-
effects, and do not warrant use in mild cases.16
• Moderate and severe disease (bacterial and fungal): A topical
preparation that contains an antibiotic, an antiseptic and a
glucocorticoid is recommended. Where a fungal infection is
suspected, topical antifungal creams and ointments would need
to be used. The antibiotic should have good coverage against
S. aureus and P. aeruginosa. The antifungal agents, clotrimazole
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
the opposite shoulder, pulling the superior aspect of the auricle
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
canal for 20 minutes, to maximise medicine exposure.
Most topical preparations should be given three to four times
daily. Topical fluoroquinolones can be given two times daily.
The course of treatment varies. The initial treatment course is
usually seven days, with follow-up. Further treatment may be
continued for up to two weeks. Patients with symptoms that
persist beyond two weeks should be re-evaluated for treatment
failure.16
Wick placement
Direct application of topical agents to the infected site is a key
element in the treatment of external otitis, regardless of severity.
Those with severe disease (i.e. a completely occluded canal) should
also have a wick placed. Wicks are commercially available, and
S Afr Pharm J
are made of compressed cotton. They expand as the ototopical
medicine is applied. The wick allows topical medications to reach
the medial aspect of the ear canal. They also facilitate longer
retention of topical solutions in the affected areas. Wicks should
be replaced every one to three days if significant swelling persists.
Wicks can be removed once ear canal swelling subsides. Wick
placement usually requires referral to an otorhinolaryngologist.16
The addition of an oral antibiotic to topical antibiotic therapy does
not appear to enhance treatment in uncomplicated external otitis.
Systemic antibiotics, in addition to topical antibiotics, are indicated
with deeper tissue infection, due to lack of adequate penetration
with topical therapy. Combined systemic and topical antibiotics
are also indicated in patients who are immunosuppressed, i.e.
post-transplant, and those receiving chemotherapy or radiation
therapy, or where there is a high risk of malignant external otitis.16
Antibiotics need to be effective against the most common
pathogens, P. aeruginosa and S. aureus. Quinolones (ciprofloxacin
or ofloxacin) usually provide necessary coverage.28 Ciprofloxacin
can be given at a dose of 500 mg twice daily, for seven to 10 days.16
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
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
Treatment course and recovery
Some symptom improvement should occur within 36-48 hours
after treatment is initiated, and full symptom resolution by six
days.15 Patients who do not respond to treatment should be
referred to an otorhinolaryngologist for further evaluation.
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