Interventions for acute otitis externa

Abstract

There is a paucity of high quality trials evaluating interventions for acute otitis externa. The results of this systematic review are largely based on odds ratios calculated from single trials, most of which have very broad 95% confidence intervals because of small to modest sample sizes. The findings may not be wholly generalisable to primary care for a variety of reasons; only two of the 19 trials included in the review were conducted in a primary care population setting, and in 11 of the 19 trials ear cleaning formed part of the treatment (an intervention unlikely to be available in primary care). Despite these reservations, some meaningful conclusions can be drawn from the evidence available:Topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa. In most cases the choice of topical intervention does not appear to influence the therapeutic outcome significantly. Any observed differences in efficacy were usually minor and not consistently present at each follow-up visit. Acetic acid was effective and comparable to antibiotic/steroid at week 1. However, when treatment needed to be extended beyond this point it was less effective. In addition, patient symptoms lasted two days longer in the acetic acid group compared to antibiotic/steroid.The evidence for steroid-only drops is very limited and as yet not robust enough to allow us to reach a conclusion or provide recommendations. Further investigation is needed.Given that most topical treatments are equally effective, it would appear that in most cases the preferred choice of topical treatment may be determined by other factors, such as risk of ototoxicity, risk of contact sensitivity, risk of developing resistance, availability, cost and dosing schedule. Factors such as speed of healing and pain relief are yet to be determined for many topical treatments and may also influence this decision.Patients prescribed antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun. Although patients are usually treated with topical medication for seven to 10 days it is apparent that this will undertreat some patients and overtreat others. It may be more useful when prescribing ear drops to instruct patients to use them for at least a week. If they have symptoms beyond the first week they should continue the drops until their symptoms resolve (and possibly for a few days after), for a maximum of a further seven days. Patients with persisting symptoms beyond two weeks should be considered treatment failures and alternative management initiated.

The Use of Systemic and Topical Fluoroquinolones

“…Eleven trials included aural toilet as a routine intervention, but the authors acknowledged that this treatment is not likely to be available in a typical primary care office setting. 38 The paucity of high-quality studies of antimicrobial agent-based topical therapy limited conclusions in this review. A small, prospective, randomized, open-label study in 50 patients with tympanostomy tube otorrhea or a tympanic membrane perforation showed comparable outcomes with either topical antibiotic therapy or topical plus systemic antibiotic agents.…”

“…38 Topical antibiotic agents containing corticosteroids appeared to be more effective than acetic acid solutions. Aminoglycoside-containing otic preparations were reported to cause ototoxicity if the tympanic membrane was not intact; fluoroquinolonecontaining preparations represent a safer alternative to treat both otorrhea associated with tympanic membrane perforation and tympanostomy tube otorrhea.…”

Clinical Practice Guideline: Acute Otitis Externa

“…Two meta-analyses have compared a quinolone drop versus neomycin-polymyxin B-hydrocortisone drop for diffuse AOE, with no significant difference in adverse events individually or when combined. 46,110 Conversely, about 30% to 60% of patients with chronic or eczematous external otitis develop a contact dermatitis, most often to aminoglycosides such as neomycin and framycetin. 62,[131][132][133][134][135] No studies are limited specifically to patients with recurrent AOE, chronic external otitis, or eczematous external otitis, but it would appear prudent to avoid using aminoglycoside drops in these populations.…”

A Comparative Study on Efficacy of Polymyxin B, Neomycin and Polymyxin B, Neomycin, Hydrocortisone in the Treatment of Otitis Externa at Nepal Medical College and Teaching Hospital, Kathmandu

“…Kaushik et al assessed the effec veness of topical an microbials containing 22 steroids with placebo for AOE. The study concluded that topical an microbials containing steroids were significantly more effec ve than placebo drops on sta s cal analysis.…”