1. Ear drops:

   Domeboro or Vosol - acidifying and drying agent

   Dispense: 30cc

   Sig: ii gtts tid

   OR

   Cortisporin Otic Suspension

   Dispense: 10cc

   Sig: ii gtts tid x 2-3 days

2. Wick:

   rolled cotton

   or

   Pope otowick (Xomed)

3. Canal Cleaning:

   While otomicroscopy and suction are preferred, irrigation is acceptable. Assuming no TM perforation 1 or 2 irrigations is ok. If no success the ear canal must be suctioned clean.

Overview of Otitis Externa

Otitis Externa (a.k.a. Swimmer's Ear) is found in individuals who swim frequently or extensively while vacationing and is found in people who are chronic Q-tip abusers. The pathogenesis is worth understanding. Normally, the external auditory canal is inhabited by a low concentration of Pseudomonas aeruginosa whose growth is inhibited by the slightly acidic pH. Those who scrape away the wax and epithelium with Q-tips, leaving an open wound which exudes a high pH, favorable growth media OR those whose ears are submersed in water for so long that the skin swells and loses its natural acidic protection, develop Pseudomonas aeruginosa perichronditis; i.e. otitis externa.

In North America, fungal infections are uncommon whereas in warm, humid environments such as the tropics they are more frequent. Treatment for otitis externa in North America, is acidification. For this reason, virtually every ear drop is buffered to an acid pH. There is a sense that drying the ear is beneficial and so hydrophilic compounds, i.e. drying agents such as alcohol are frequently added. To whatever degree one believes that antibiotics and/or steroids would provide benefit, they too are added to some of the prescription ear drops.

The standard "swimmer's ear" is treated with any one of a number of commercial ear drops. One two or three drops carefully placed in the external auditory canal two, three or four times a day will normally cure the illness in one, at the most two, days. The inflammed ear canal is painful. Don't be afraid to recommend aspirin or other analgesic. Heat, such as a heating pad, will also provide significant comfort.

If there is desquamated epithelium or other debris in the external auditory canal, the ear drops will not reach the ear canal's skin surface. Therefore, this material should be removed. The easiest is with irrigation. ENT doctors suction under direct vision, often with the benefit of a microscope. With the ear canal clean, the ear drops are now efficacious. In some cases the ear canal is so edematous that it is swollen shut. The ear drops will not pass through and a wick, either a rolled wisp of cotton or the commercially available Merocel wicks, are necessary. They have to be forcefully placed into the external canal and then will wick the eardrops into the canal.

Garden variety, run of the mill, otitis externa is easily treated with Domboro otic or Vosol otic. If there appears to be a more advanced infection, particularly with a more significant bacterial component, polymyxin otics are popular and contain antibiotics and steroids. An occasional patient develops an allergic reaction to the polymyxins. If the antibacterial properties wish to be continued, Gentamicin or Tobramycin ophthalmic can be safely administered to the external ear canal and have come popular as otic medicaments.

Diabetics are at risk for developing a Pseudomonas osteomyelitis of the temporal bone. This looks like otitis externa. The pain is greater and the disease is more severe. This is a fatal disease unless promptly diagnosed and aggressively treated.

Oral antibiotics are never given for otitis externa. For such to be effective, they would need to cover Pseudomonas. Penicillin, ampicillin, amoxicillin, erythromycin, cephlosporins and sulfonamides do not.

The patient with a perforated ear drum, with pus draining out the external auditory canal will have a reactive otitis externa. Antibiotic containing ear drops are normally administered, in part to treat the otitis externa and in part because they help treat the otitis media. In these cases, a quinolone ear drop (e.g. Floxin Otic) is preferred.

The inflammation of otitis externa virtually never extends off of the ear. If erythema extends beyond the auricle, the diagnosis is not otitis externa, but cellulitis or an insect bite.

The individual who is a daily swimmer, may develop a chronic otitis externa. These are easily treated with non-antibiotic, non-steroid containing otic drops at the end of each swimming session. Domeboro otic and Vosol otic are the two most commonly prescribed.

Lastly, if pharmaceuticals are not available, either for financial reasons or one is on an outing away from pharmaceutical amenities, a home brew ear drop is one part white table vinegar, one part 70% isopropyl alcohol and one part water. This is odiferous, but effective.