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Otitis externa - Management
How should I treat chronic otitis externa?

  • Apply general measures, as for acute diffuse otitis externa. The aims are to: keep the ear canal dry and free of debris and discharge while avoiding injuring it; relieve itch and pain; remove any precipitating antigens or irritants; treat any underlying skin condition such as seborrhoeic dermatitis.
  • Treatment may be difficult, and may require trials of more than one strategy.
  • If fungal infection is suspected (signs of fungal growth in ear canal):
    • Prescribe a topical antifungal preparation.
    • Seek specialist advice if there is inadequate response.
  • If the cause seems to be seborrhoeic dermatitis:
    • Treat topically with an antifungal–corticosteroid combination.
  • If no cause is evident:
    • Prescribe a 7-day course of a topical preparation containing only a corticosteroid without antibiotic. Consider co-prescribing an acetic acid spray.
    • If there is an adequate response:
      • The corticosteroid treatment may need to be continued. Reduce the potency of the corticosteroid and/or the frequency of application to the minimum required to maintain control.
      • If treatment cannot be withdrawn after 2 or 3 months, seek specialist advice.
    • If the response is inadequate, consider a trial of a topical antifungal preparation.
Clarification / Additional information
  • Avoid preparations containing ingredients that can cause an allergic or reactive dermatitis, such as aminoglycosides (which may all cross-react).
  • Topical antifungal preparations:
    • For mild-to-moderate and uncomplicated fungal infections, treat either with:
      • A topical antifungal: clotrimazole 1% solution.
      • Acetic acid 2% spray (unlicensed use).
      • A topical preparation containing clioquinol and a corticosteroid e.g. Locorten–Vioform®.
Basis for recommendation
  • Because treatment strategies for chronic otitis externa have not been studied in clinical trials, these recommendations are pragmatic advice, largely based on expert opinion [Roland, 2001; Osguthorpe and Nielsen, 2006].
  • Topical antifungal preparations:
    • CKS is unable to find any randomized trials comparing the acetic acid 2% spray and a topical antifungal.
    • Acetic acid 2% ear spray:
      • Acidic preparations are thought to reduce the pH in the external auditory canal, thus restricting the growth of bacteria and fungal infections which flourish in an alkaline environment (pH 8–10) [Dohar, 2003].
      • Acetic acid 2% ear spray (Earcalm®) is only licensed for the treatment of superficial infections of the external auditory canal.
    • Clioquinol can also be considered as it possesses antibacterial and antifungal activities [ABPI Medicines Compendium, 2007; BNF 53, 2007].

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