According to Dr. Rutka, one of the main reasons for treatment failure is the excessive swelling that prohibits the topical agent from contacting the entire external auditory canal. The use of a wick acts as a hygroscopic agent and vehicle carrier that will draw fluid from the inflammation but will also allow the drops to get down [the canal], he said.
Explore This IssueJune 2009
Pay Attention to Pain
Critical to the accurate diagnosis and optimal treatment of a patient with swimmer’s ear is consideration of the degree of pain the person is suffering. According to Alan Micco, MD, Chief of Otology and Neurotology at Northwestern University in Chicago, inordinate pain should alert the otolaryngologist that a patient may have a more complicated case of otitis externa.
Malignant otitis externa or necrotizing otitis externa, the most serious complication, occurs when the bacterial infection gets into the middle and inner ear and spreads to the bone at the base of the skull. Although rare, the seriousness of the complication can be fatal; therefore, swift and accurate diagnosis and treatment with oral antibiotics is necessary.
People at increased risk of this complication are those with diabetes and those with compromised immune systems from diseases such as HIV or from treatment such as chemotherapy. People with these risk factors who present with otitis externa should be screened and treated more aggressively. Although it is generally not used to treat otitis externa, irrigation of the ear for wax buildup, which may predispose a person to developing otitis externa, is ill advised particularly in people with diabetes, given reports of malignant otitis externa developing in these patients after ear irrigation with tap water.
Another complication that can occur, particularly after prolonged use of topical antibiotic and steroidal drops, is a secondary fungal infection. What typically happens is that the acute pain goes away and then the ear becomes blocked and itchy, said Dr. Rutka, adding that this can be treated by cleaning out the ear and stopping the use of the drops. In some cases, he said, antifungal treatment may be required.
Along with using pain as a guide to accurate diagnosis, controlling pain should also be a critical part of treatment. Dr. Rutka recommends including pain medication with an oral anti-inflammatory such as Celebrex.
For people who are prone to or frequently develop acute otitis externa, Dr. Gianoli recommends a rinsing out the ears with a home brew of one part rubbing alcohol and one part white vinegar. The alcohol helps desiccate the ear, and the vinegar acidifies the ear and prevents the bacteria from getting a foothold, he said, adding that the solution should be at body temperature to avoid an inadvertent caloric test.