Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – External Otitis
EXTERNAL OTITIS
An inflammation of the external auditory canal, commonly known as “swimmer’s ear,” that is characterized by inflammation, pruritus, and pain that is exacerbated by movement of pinna or tragus.
I. Etiology
A. Bacterial: Pseudomonas, Streptococcus, Pneumococcus
B. Fungal: Candida, Aspergillus
C. Maceration, trauma, or excessive dryness of the lining of the ear canal causes it to be susceptible to superimposed infection.
D. Excess cerumen
E. Secondary to tympanic membrane perforation with purulent drainage
F. Secondary to seborrheic dermatitis or atopic dermatitis.
II. Incidence
A. It is most often seen in the summer, particularly in areas where swimming in fresh water is popular.
B. It is seen year-round, but most often in adolescents who shampoo daily and where year-round swimming pools are available.
C. It is not unusual to find external otitis in an infant who has a bottle in bed because of milk dribbling into the ear canal, keeping it moist and providing a medium for bacterial growth.
III. Subjective data
A. Pain in the ear
B. Pain on movement of earlobe or when ear is touched
C. Pain when chewing
D. Sensation of itching or moisture in ear canal
E. Discharge from ear
F. Pertinent subjective data to obtain
1. History of child putting anything in the ears
2. History of use of cotton swabs to clean ear canals
3. History of swimming, particularly in fresh water
4. History of frequent showers or shampoos
5. History of use of hair sprays
6. History of otitis media with perforation
7. History of use of earplugs
8. Previous history of otitis externa
9. History of seborrhea or atopic dermatitis
IV. Objective data
A. Exacerbation of pain on movement of pinna or application of pressure on tragus
B. Exquisite tenderness of canal on insertion of speculum
C. Canal
1. Edematous
2. Erythematous
3. Exudative: Exudate may have foul odor.
D. Tympanic membrane
1. May not be clearly visualized because of edema and exudate in canal
2. May be inflamed with a widespread external otitis
3. May be perforated if otitis externa is secondary to otitis media
E. Pinna: May be inflamed and edematous
F. Adenopathy: Ipsilateral preauricular, postauricular, cervical
G. Preauricular edema
H. Laboratory tests: Bacterial cultures using a calcium alginate nasopharyngeal swab to identify causative organism
V. Assessment
A. Diagnosis is confirmed by the characteristic inflammation and edema of the ear canal and exacerbation of pain with movement of pinna and pressure on tragus.
B. Differential diagnosis
VI. Plan
1. Otitis media with secondary otitis externa: History of acute otitis media with perforation
2. Foreign body: By history and visualization of foreign body
3. Abscess in ear canal: Mass visualized in canal
4. Furunculosis: Discrete furuncle or pustule with surrounding erythema visualized in canal
A. External otitis involving only the ear canal
1. Clean debris from canal.
2. If severe swelling precludes instillation of topical medication, place a wick in canal to facilitate drug delivery.
3. Topical treatment—provides a higher concentration to affected area:
a. Floxin Otic 0.3% solution: 6 months to 13 years age, 5 drops in affected ear once daily for 7 days; over 13 years of age, 10 drops in affected ear once daily for 7 days
or
b. Cipro HC Otic: more than 1 year of age, 3 drops in affected ear bid for 7 days
or
c. Cortisporin Otic: 4 drops in affected ear tid or qid for 10 days or
d. Ciprodex Otic: More than 6 months, 4 drops in affected ear bid for 7 days
4. Note: Do not order generic eardrops. They have been associated with increased complaints of pain on instillation, resulting in decreased compliance.
5. Aspirin, acetaminophen, or codeine for pain
B. External otitis with fever, tympanic membrane involvement, cellulitis of pinna, or tender postauricular adenopathy should be treated with systemic antibiotics as well.
1. Intact tympanic membrane (TM):
a. topical treatment above
2. Perforated TM or TM not visualized:
a. Oflaxacin: 6 months–13 years, 5 drops in affected ear once daily. Over 13 years, 10 drops in affected ear daily for 7 days. or
b. Ciprofloxacin dexamethasone: Over 6 months, 4 drops in affected ear twice daily.
3. Augmentin: 45 mg/kg/d in 2 divided doses every 12 hours. or if penicillin allergic:
4. Biaxin: 15 mg/kg/d in 2 divided doses; more than 33 kg, 250 mg bid
5. Aspirin, acetaminophen, or codeine for pain (see Drug Index, p. 441)
C. Recurrent external otitis
1. Follow initial treatment plan above. After final recheck, use one of the following for prophylaxis during the swimming season:
a. Otic Domeboro Solution: 5 drops in each ear after swimming or
b. V-Sol Otic Solution: 5 drops in each ear after swimming
2. In external otitis, the pH of the canal changes from acid to alkaline, creating a favorable environment for bacterial and mycotic overgrowth. Domeboro and V-Sol are antibacterial and antifungal with an acid pH and are effective in preventing recurrences.
VII. Education
A. Explain etiology to child and parent.
B. Medication
1. Acute pain should subside within 24 to 48 hours of treatment.
2. Call office if no apparent response to medication.
3. Cortisporin otic drops contain an antibiotic as well as cortisone to decrease inflammation.
4. Side effects of ear drops may be a local stinging or burning sensation or a rash where drops have come in contact with the skin.
5. Drops should be body temperature. Warm in hand prior to instillation.
6. For instillation of drops, child should lie on the side with the affected ear up. Pull tip of auricle up and back, and then instill drops without allowing dropper to touch ear. Child should remain in this position for at least 5 minutes.
7. With more extensive involvement and treatment with systemic antibiotics, medication should be taken for 10 full days, even if child seems better.
C. Ear canal must be kept dry.
1. No swimming
2. No shampoos (without protection)
3. No showers
4. Do not use cotton in ears; it will retain moisture.
5. Do not use earplugs.
6. Lamb’s wool is water repellent and can be used to occlude canal for shampoos.
7. Malleable ear plug or Silly Putty may be used after the acute phase to keep canal dry while bathing or shampooing.
8. Do not use cotton swabs.
D. Recurrences are not uncommon, especially in adolescents who swim, shower, or shampoo daily. Many of them also use cotton swabs to dry and clean their ears. Suggest instillation of 2 to 3 drops of alcohol to dry ears after showering or swimming or dry canals with hairdryer on low heat.
VIII. Follow-up
A. Recheck in 48 to 72 hours if there is marked cellulitis and tympanic membrane is not visualized.
B. Recheck in 48 to 72 hours if no clinical improvement.
C. Recheck immediately if suspected sensitivity to ear drops or child complains of increase in pain.
D. Recheck in 7–10 days. If not completely resolved, continue medication and precautions. Recheck again in 10 days.
IX. Complications
A. Hypersensitivity reaction to ear drops (cutaneous reaction to neomycin)
B. Recurrent external otitis
C. Malignant otitis externa.
X. Consultation/referral
A. Symptoms worse after 24 hours of treatment
B. No response to treatment in 48 to 72 hours
C. External otitis not markedly improved at 10-day recheck
D. Foreign body in ear canal not readily removed
E. Immunocompromised child with question of malignant otitis externa