Mar. 29, 2006 An expert panel representing the fields of otolaryngology – head and neck surgery, pediatrics, family medicine, infectious disease, internal medicine, emergency medicine, and medical informatics, has issued new guidelines providing evidence-based recommendations for management of acute otitis externa (AOE), or “swimmer’s ear.” This condition, affecting one in every 100-250 Americans each year, is characterized by inflammation of the external ear canal and is caused by water trapped in the ear canal, an occurrence that follows swimming in pools, lakes, or the ocean. The trapped water leads bacteria that normally inhabit the skin and ear canal to multiply, causing infection and irritation of the ear canal.
A key recommendation made by the panel is that topical preparations, such as ear drops, should be used for initial treatment of acute otitis externa. The physician specialists also state that antibiotics, administered orally, should not be used as treatment unless there is extension outside of the ear canal or the presence of other symptoms that would necessitate a need for systemic therapy. The panel further recommends that selection of a topical antimicrobial therapy for diffusing AOE should be based upon efficacy, low incidence of adverse events, likelihood of adherence to therapy, and cost.
These are the first guidelines issued addressing the appropriate diagnosis and treatment of acute otitis externa. The authors of “Clinical Practice Guideline: Acute Otitis Externa,” are Richard M. Rosenfeld, MD, MPH, from SUNY Downstate Medical Center and Long Island College Hospital; Lance Brown MD, MPH, from the Loma Linda University Medical Center; C. Ron Cannon, MD, at the University of Mississippi School of Medicine and University of Mississippi School of Dentistry; Rowena J. Dolor, MD, MHS, Sandra S. Stinnett, DrPH, and David L. Witsell, MD, MHS, all at the Duke University Medical Center; Theodore G. Ganiats, MD, with the University of California San Diego; S. Michael Marcy, MD, affiliated with the University of California-Los Angeles; Peter S. Roland, MD, University of Texas Southwestern School of Medicine; Richard N. Shiffman, MD, MCIS, with the Yale University School of Medicine; and Maureen Hannley, PhD, and Phillip Kokemueller, both with the American Academy of Otolaryngology – Head and Neck Surgery Foundation. The new guidelines are being published in the April 2006 edition of Otolaryngology—Head and Neck Surgery, the medical journal for the American Academy of Otolaryngology—Head and Neck Surgery Foundation.
Methodology: The expert panel of specialists conducted a meta-analysis using an a priori protocol and a published search strategy for AOE to compare the following topical treatments: antimicrobial vs. placebo, antiseptic vs. antimicrobial, quinolone antibiotic vs. non-quinolone, steroid-antimicrobial vs. antimicrobial, or antimicrobial-steroid vs. steroid. A search of MEDLINE from 1966 through July 2005 identified 2860 articles, of which 509 were potential randomized trials. Review of these studies, plus seven others found in the Cochrane Database, yielded 43 articles, which were assessed by two reviewers independently for relevance, study quality, and data extraction. The final data set included 20 articles that had random allocation and were limited to diffuse AOE (or had subgroup data). Additionally, some 240 articles that provided a foundation for the development of the guidelines.
The panel met twice during the seven months devoted to guideline development with interval electronic review and feedback on each guideline draft to ensure accuracy of content and consistency with standardized criteria for reporting clinical practice guidelines. The final draft guideline underwent extensive external peer review. Comments were compiled and reviewed by the group chairperson. The recommendations contained in the practice guideline are based on the best available published data through September 2005.
Results: Key points articulated in the guidelines are:
• Ear pain from AOE is often severe and can interfere with work or leisure activities; with proper therapy, pain usually improves after one day and resolves in 4-7 days
• Antiseptic and antibiotic eardrops are the preferred therapy for most AOE, because they are safe, give prompt relief, and (importantly) do not promote resistant bacteria
• Oral antibiotics, although often used to treat AOE, are not recommended for uncomplicated cases because they have more adverse effects than eardrops and may be less effective
• Patients with a tympanostomy tube or perforated eardrum should use one of the newer, quinolone antibiotic eardrops that are approved for this purpose and do not cause hearing loss
• Eardrops are only effective when administered properly; clinicians should inform patients how to use eardrops, clean obstructing debris from the ear canal, and insert a wick, when necessary, to allow the drops to enter the ear canal if it is very swollen
• Oral antibiotics are appropriate for AOE that is complicated by cellulites beyond the ear canal, or by host factors that include diabetes, immune deficiency, or inability to deliver topical therapy despite cleaning of the ear canal, inserting a wick, or both.
• Ear candles are not recommended for treating AOE because they have never been shown efficacious, and have dangerous side effects that include burns and perforated eardrum.
Results: The guidelines provide clear direction for the clinical diagnosis and treatment of an ear disorder that, when severe, can be highly debilitating. As Americans, young and old, continue to venture into the water, the recommendations should assist in providing safe, effective, treatment for this disorder.
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