Successful Management of Uncomplicated Otitis Externa Using Short-Course Hydrocortisone-Oxytetracycline Ear Packing

Successful Management of Uncomplicated Otitis Externa Using Short-Course Hydrocortisone-Oxytetracycline Ear Packing | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Successful Management of Uncomplicated Otitis Externa Using Short-Course Hydrocortisone-Oxytetracycline Ear Packing Rinor Ajeti, Afrim Ajeti, Vesna Petreska Dukovska This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6698056/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : To describe the efficacy of clinician-administered hydrocortisone-oxytetracycline ear packing over three sessions in resolving uncomplicated otitis externa (OE). Case Presentation : A 34-year-old male with acute OE presented with severe pain, canal edema, and moderate discharge. Previous self-administered topical therapy had failed. Treatment involved three sessions of hydrocortisone-oxytetracycline-soaked ear packing over six days. Pain reduced by 40% at 48 hours and resolved completely by day 6. Edema and discharge progressively resolved, with full clinical recovery by day 6. No adverse events occurred. Conclusion : Structured ear packing offers a faster, safer alternative to conventional self-administered drops, ensuring rapid recovery and high patient comfort. Otitis externa ear packing hydrocortisone-oxytetracycline topical therapy short-course treatment Background Otitis externa (OE), commonly referred to as "swimmer's ear," is an acute or chronic inflammation of the external auditory canal. It is a frequent cause of ear-related discomfort in both primary care and otolaryngology clinics and accounts for approximately 10% of otologic complaints [ 1 ]. OE affects individuals of all ages, with increased prevalence in children and young adults, especially during the summer months due to increased humidity and water exposure [2,3]. The pathophysiology of OE involves a disruption in the protective barriers of the external ear canal, leading to colonization by pathogenic microorganisms. The most frequently isolated organisms include Pseudomonas aeruginosa and Staphylococcus aureus [ 4 ], although fungi and mixed infections are not uncommon [5]. Clinically, OE presents with symptoms such as otalgia, itching, fullness, otorrhea, and decreased hearing. Examination findings often include canal edema, erythema, tenderness upon tragal manipulation, and in severe cases, occlusion of the canal lumen [ 6 ]. If left untreated or improperly managed, OE can progress to perichondritis or malignant otitis externa, particularly in immunocompromised individuals [ 7 ]. Current guidelines recommend topical antimicrobial agents as the first-line treatment, often in combination with corticosteroids to reduce inflammation [ 1 ]. However, effective delivery of medication can be hampered by edema and debris within the canal, resulting in incomplete resolution and recurrence. Additionally, compliance with self-administered drops is a persistent challenge, particularly in elderly patients and children [ 8 , 9 ]. Hydrocortisone-oxytetracycline ointment packing offers a promising alternative. This method ensures prolonged and uniform drug exposure directly to the affected site and helps mechanically reduce edema by maintaining patency of the canal. It also avoids issues associated with preservatives present in ear drops and mitigates the need for frequent dosing by the patient [ 10 , 11 ]. In addition, this method is particularly beneficial in patients with anatomical variations or post-surgical changes in the external canal, where drop penetration is especially challenging [ 12 ]. In this case report, we present a patient with uncomplicated OE successfully treated using a structured short-course protocol of clinician-administered hydrocortisone-oxytetracycline ear packing Case Presentation Patient History A 34-year-old male presented with four days of right ear pain, itching, and purulent discharge. He had a prior episode of similar symptoms approximately one year ago, which was managed with self-administered ciprofloxacin-dexamethasone drops with incomplete resolution. His medical history was otherwise unremarkable, with no known comorbidities such as diabetes or immunodeficiency. He reported recent use of cotton swabs and swimming in public pools. Clinical Findings On examination, the right external auditory canal appeared erythematous and edematous (graded 2 out of 3), with yellowish seropurulent discharge partially obstructing the view of the tympanic membrane. The membrane itself was intact and mobile. There was marked tenderness upon manipulation of the tragus and pinna. No cervical lymphadenopathy or systemic symptoms were observed. Intervention Intervention Under otomicroscopic guidance, the canal was gently cleaned with suction to remove debris. A 1 cm × 3 cm sterile gauze wick impregnated with a hydrocortisone 1% and oxytetracycline 3% ointment (Hydrocyclin®) was inserted into the canal. The wick was replaced every 48 hours over three sessions on days 1, 3, and 5. The patient was also advised to use oral ibuprofen 400 mg as needed for pain relief. Follow-Up and Outcomes At Day 3 follow-up, he confirmed 40% reduction in pain and discharge. The canal was less edematous, and there was marked reduction in discharge. The condition improved by more than 75% on day 5, with only a tiny edematous lesion. There was no pain, and no discharge or inflammation at all the 6th day. On otoscopy, the ear canal was found to be normal and the tympanic membrane was of normal appearance. The treatment was rated as very tolerable, and only minimal discomfort was felt on packing and removal. Analgesics were only used in the first 2 days. Otitis externa is an often undeniably miserable condition, which impinges on quality of life [ 1 ]. The aim of treatment is rapid link resolution of the infection and inflammation, with a minimum of complications and relapse. Although the classical eardrops method is generally accepted, there are several limitations in some situations. Anatomical obstruction by edema, the presence of debris, and wrong self-administration technique are some of the factors responsible for therapeutic failure [ 2 ]. Medicated packing attempts to circumvent many of these problems by allowing direct contact of medication with the inflamed mucosa and by keeping the canal open. In addition, the use of ointments versus liquid preparations obviates the requirement for preservatives, which may reduce allergic sensitization and ototoxicity [3]. The hydrocortisone element exerts a powerful anti-inflammatory action by reducing capillary permeability and blocking leukocyte migration, whereas oxytetracycline is active against a wide range of gram positive and negative organisms by inhibiting bacterial protein synthesis [ 4 ]. A number of clinical studies have shown that ear packing, especially when combined with antibiotic-steroids is more effective in symptoms resolution than drops alone [5]. Abelardo et al. also reported a randomized trial where patients on combination therapy experienced a faster resolution of their symptoms and lower recurrence rates [ 6 ]. Bhatt et al. also demonstrated the advantage of gauze packing for pain and canal caliber over drops alone in a study of 60 patients [ 7 ]. Studies further indicate that packing lessens adherence demands onthe patient, eases gauging of progress bythe clinician, and allows better hygiene with discharge con trol [ 8 ]. Apart from its clinical application, packing has significant advantages in resource poor environment and when adherence to the outpatient therapy is an issue. When combined with patient education and meticulous follow-up, packing is not only a therapeutic measure, but also a means of prevention [ 9 ]. Pharmacological Theory of Packing Therapy Hydrocortisone, a corticosteroid with anti-inflammatory, anti-pruritic, and vasoconstrictive activity, is also indicated. In OE, it has tissue edema reduction effects, erythema relief effects, and local immunity inhibition effects. Oxytetracycline is a tetracycline antibiotic which is effective bacteria agent with actions on the 30S ribosomal subunit of bacteria that inhibit the addition of amino acids to growing peptide chains in bacteria, which result in the suppression of bacterial growth [ 10 ]. A swift, symptomatic relief is obtained through the combination, and the infection origin that underlies is also eliminated. Ointment Vehicles Ointment vehicles also encourage prolonged contact of the drug with the walls of the canal, thereby favoring absorption and helping to maintain local effective concentrations. This retention for extended periods of time, in contrast with that of drops, that are either drained out too early or get trapped in oedema [ 11 ]. Methods Rationale and Clinical Implications The time-limited, time structured and effective therapeutic window of three 1-hour sessions used in this case. It balanced exposure to unnecessary antibiotics with efficacy. The timing of dressing changes permitted re-evaluation and canal cleansing with attention to patient comfort. This way of procedure could be a standard protocol, specifically, at the ENT outpatient clinic. It is also consistent with good antimicrobial stewardship, spanning use of therapy to effectively everything and leaving systemic antibiotics only when necessary. From a public health standpoint, promotion of clinician-directed short-course topical therapy may potentially lower drug resistance and treatment failures [ 12 ]. However, restrictions need to be considered. This was an anecdotal report, and there was no microbiological confirmation. Common presenting features and early response were consistent with bacterial OE; however, culture-directed therapy might be helpful in future studies. Additionally, economic concerns and the availability of otomicroscopic facilities may limit the practicality of this approach in particular conditions. Clinical Relevance Expanded Beyond patient-specific care, integration of clinician applied ear packing has impact on public health and practice. Its simplicity, low cost, and high success rate make it an attractive option, especially in the rural and resource-limited environment where topical drops (especially of the different classes with more durability) may not be readily accessible or used properly. The method also diminishes the reliance on self-treatment by the patient, an essential variable in determining the success of therapy of OE. Additionally, OE preventive education, especially for modifiable risk factors such as ear hygiene, excessive moisture, and trauma caused by the use of objects for ear cleaning is also important for the reduction of incidence rates. Addition of preventive counseling to the treatment visit offers a potential for benefit and reduction of future recurrence. It is widely considered that incorporation of patient education to mechanical and pharmacological interventions leads to better long-term resolution of OE [ 13 – 15 ]. Notably, environmental exposures, including freshwater swimming, have been recognized as predisposing risk factors for OE [ 14 ]. Further prospective trials may also investigate the economic effect of OE care in outpatient versus inpatient scenario, and highlight on wellness advocation by preventive protocols. Conclusions Short-course hydrocortisone-oxytetracycline ear packing was successful in the management of uncomplicated otitis externa in this instance. This technique provided a rapid relief of symptoms, eliminated complications due to drops being taken by the patient and provided a more reproducible delivery of medication. This modality is mechanically superior and has better pharmacologic properties, so it deserves consideration as first-line therapy in canal obstruction or non-compliant patients. It would be also useful to have more evidence from randomized controlled studies, multi-center investigations and economic impact analysis to confirm the superiority of packing protocols over conventional drop method. There should be a commitment to improved clinician education into packing methods and patient education with more widespread adoption. Abbreviations OE Otitis Externa Declarations Ethics Approval and Consent to Participate Not applicable. Funding This study received no external funding. References Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: Acute otitis externa. Otolaryngol Head Neck Surg . 2014;150(1_suppl):S1–S24. https://doi.org/10.1177/0194599813517083 Roland PS, Stroman DW. Microbiology of acute otitis externa. Laryngoscope . 2002;112(7 Pt 1):1166–1177. https://doi.org/10.1097/00005537-200207000-00004 Bhatt R, Pokhrel R, Adhikari P, Neupane Y. A comparison of 10% ichthammol glycerine pack with steroid-antibiotic pack for relieving pain in cases of acute otitis externa. J Inst Med . 2009;31(1):7–10. Agius AM, Pickles JM, Burch KL. A prospective study of otitis externa. Clin Otolaryngol . 1992;17(2):150–154. https://doi.org/10.1111/j.1365-2273.1992.tb01063.x Abelardo E, Pope L, Rajkumar K, Greenwood R, Nunez DA. A double-blind randomized clinical trial of the treatment of otitis externa using topical steroid alone versus topical steroid-antibiotic therapy. Eur Arch Otorhinolaryngol . 2009;266(1):41–45. https://doi.org/10.1007/s00405-008-0706-7 Gray RF, Sharma A, Vowler SL. Relative humidity of the external auditory canal in normal and abnormal ears, and its pathogenic effect. Clin Otolaryngol . 2005;30(2):105–111. https://doi.org/10.1111/j.1365-2273.2004.00950.x Wiegand S, Berner R, Schneider A, Lundershausen E, Dietz A. Otitis externa: Investigation and evidence-based treatment. Dtsch Arztebl Int . 2019;116(13):224–230. https://doi.org/10.3238/arztebl.2019.0224 Guss J, Ruckenstein MJ. Infections of the external ear. In: Flint PW, Haughey BH, Lund VJ, et al. Cummings Otolaryngology – Head and Neck Surgery . 6th ed. Philadelphia: Elsevier; 2015. p. 1944–1949. Malcolm P. Furunculosis. In: Gleeson M, editor. Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery . 7th ed. Vol. 3. London: Edward Arnold; 2008. p. 3394–3395. Sundström J, Jacobson K, Munck-Wikland E, Ringertz S. Pseudomonas aeruginosa in otitis externa. Arch Otolaryngol Head Neck Surg . 1996;122(8):833–836. https://doi.org/10.1001/archotol.1996.01890200023004 Smith IM, Keay DG, Buxton PK. Contact hypersensitivity in patients with chronic otitis externa. Clin Otolaryngol . 1990;15(2):155–158. https://doi.org/10.1111/j.1365-2273.1990.tb00449.x Medina-Blasini Y, Sharman T. Otitis Externa. In: StatPearls [Internet] . Treasure Island (FL): StatPearls Publishing; 2024. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556055/ Waitzman AA. Otitis Externa. Medscape . Updated March 5, 2024. Available from: https://emedicine.medscape.com/article/994550-overview Springer GL, Shapiro ED. Fresh water swimming as a risk factor for otitis externa: a case-controlled study. Arch Environ Health . 1985;40(4):202–206. https://doi.org/10.1080/00039896.1985.10545931 Russell JD, Donnelly M, McShane DP, et al. What causes acute otitis externa? J Laryngol Otol . 1993;107(10):898–901. https://doi.org/10.1017/s0022215100124739 Additional Declarations No competing interests reported. Supplementary Files CAREChecklistCaseReportOELinesPages.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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It is a frequent cause of ear-related discomfort in both primary care and otolaryngology clinics and accounts for approximately 10% of otologic complaints [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. OE affects individuals of all ages, with increased prevalence in children and young adults, especially during the summer months due to increased humidity and water exposure [2,3].\u003c/p\u003e\u003cp\u003eThe pathophysiology of OE involves a disruption in the protective barriers of the external ear canal, leading to colonization by pathogenic microorganisms. The most frequently isolated organisms include \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e and \u003cem\u003eStaphylococcus aureus\u003c/em\u003e [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e4\u003c/span\u003e], although fungi and mixed infections are not uncommon [5].\u003c/p\u003e\u003cp\u003eClinically, OE presents with symptoms such as otalgia, itching, fullness, otorrhea, and decreased hearing. Examination findings often include canal edema, erythema, tenderness upon tragal manipulation, and in severe cases, occlusion of the canal lumen [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. If left untreated or improperly managed, OE can progress to perichondritis or malignant otitis externa, particularly in immunocompromised individuals [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCurrent guidelines recommend topical antimicrobial agents as the first-line treatment, often in combination with corticosteroids to reduce inflammation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, effective delivery of medication can be hampered by edema and debris within the canal, resulting in incomplete resolution and recurrence. Additionally, compliance with self-administered drops is a persistent challenge, particularly in elderly patients and children [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHydrocortisone-oxytetracycline ointment packing offers a promising alternative. This method ensures prolonged and uniform drug exposure directly to the affected site and helps mechanically reduce edema by maintaining patency of the canal. It also avoids issues associated with preservatives present in ear drops and mitigates the need for frequent dosing by the patient [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn addition, this method is particularly beneficial in patients with anatomical variations or post-surgical changes in the external canal, where drop penetration is especially challenging [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this case report, we present a patient with uncomplicated OE successfully treated using a structured short-course protocol of clinician-administered hydrocortisone-oxytetracycline ear packing\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatient History\u003c/h2\u003e\u003cp\u003eA 34-year-old male presented with four days of right ear pain, itching, and purulent discharge. He had a prior episode of similar symptoms approximately one year ago, which was managed with self-administered ciprofloxacin-dexamethasone drops with incomplete resolution. His medical history was otherwise unremarkable, with no known comorbidities such as diabetes or immunodeficiency. He reported recent use of cotton swabs and swimming in public pools.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eClinical Findings\u003c/h3\u003e\n\u003cp\u003eOn examination, the right external auditory canal appeared erythematous and edematous (graded 2 out of 3), with yellowish seropurulent discharge partially obstructing the view of the tympanic membrane. The membrane itself was intact and mobile. There was marked tenderness upon manipulation of the tragus and pinna. No cervical lymphadenopathy or systemic symptoms were observed.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eIntervention\u003c/div\u003e\u003cp\u003eUnder otomicroscopic guidance, the canal was gently cleaned with suction to remove debris. A 1 cm \u0026times; 3 cm sterile gauze wick impregnated with a hydrocortisone 1% and oxytetracycline 3% ointment (Hydrocyclin\u0026reg;) was inserted into the canal. The wick was replaced every 48 hours over three sessions on days 1, 3, and 5. The patient was also advised to use oral ibuprofen 400 mg as needed for pain relief.\u003c/p\u003e\n\u003ch3\u003eFollow-Up and Outcomes\u003c/h3\u003e\n\u003cp\u003eAt Day 3 follow-up, he\u0026ensp;confirmed 40% reduction in pain and discharge. The canal was less edematous,\u0026ensp;and there was marked reduction in discharge. The condition improved by\u0026ensp;more than 75% on day 5, with only a tiny edematous lesion. There was no pain, and no discharge or inflammation at all the 6th\u0026ensp;day. On otoscopy, the ear canal was found to\u0026ensp;be normal and the tympanic membrane was of normal appearance. The treatment was rated as very tolerable,\u0026ensp;and only minimal discomfort was felt on packing and removal. Analgesics were only used in the first\u0026ensp;2 days.\u003c/p\u003e\u003cp\u003eOtitis externa is an often undeniably miserable condition, which impinges on quality of life\u0026ensp;[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The aim of treatment is rapid link resolution of the infection and inflammation, with a minimum of\u0026ensp;complications and relapse. Although the classical eardrops method is generally accepted, there are several\u0026ensp;limitations in some situations. Anatomical obstruction by edema, the presence of debris, and wrong self-administration technique are some of the\u0026ensp;factors responsible for therapeutic failure [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMedicated packing attempts to\u0026ensp;circumvent many of these problems by allowing direct contact of medication with the inflamed mucosa and by keeping the canal open. In addition,\u0026ensp;the use of ointments versus liquid preparations obviates the requirement for preservatives, which may reduce allergic sensitization and ototoxicity [3]. The hydrocortisone element exerts a powerful anti-inflammatory action by reducing capillary permeability and blocking leukocyte migration, whereas oxytetracycline is active against a wide range of gram positive and negative organisms\u0026ensp;by inhibiting bacterial protein synthesis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA number of clinical studies have shown that ear packing, especially\u0026ensp;when combined with antibiotic-steroids is more effective in symptoms resolution than drops alone [5]. Abelardo et al. also reported a randomized trial where patients on combination therapy experienced a\u0026ensp;faster resolution of their symptoms and lower recurrence rates [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Bhatt et al. also demonstrated\u0026ensp;the advantage of gauze packing for pain and canal caliber over drops alone in a study of 60 patients [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStudies\u0026ensp;further indicate that packing lessens adherence demands onthe patient, eases gauging of progress bythe clinician, and allows better hygiene with discharge con trol [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Apart from its\u0026ensp;clinical application, packing has significant advantages in resource poor environment and when adherence to the outpatient therapy is an issue. When combined with patient education and meticulous follow-up, packing is not only a\u0026ensp;therapeutic measure, but also a means of prevention [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003ePharmacological Theory of Packing Therapy\u003c/h3\u003e\n\u003cp\u003eHydrocortisone, a corticosteroid with\u0026ensp;anti-inflammatory, anti-pruritic, and vasoconstrictive activity, is also indicated. In OE, it has tissue edema reduction effects, erythema relief\u0026ensp;effects, and local immunity inhibition effects. Oxytetracycline is a tetracycline antibiotic which is effective bacteria agent with actions on the 30S ribosomal subunit of bacteria that inhibit the addition of amino acids to growing\u0026ensp;peptide chains in bacteria, which result in the suppression of bacterial growth [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A\u0026ensp;swift, symptomatic relief is obtained through the combination, and the infection origin that underlies is also eliminated.\u003c/p\u003e\u003cp\u003eOintment\u0026ensp;Vehicles Ointment vehicles also encourage prolonged contact of the drug with the walls of the canal, thereby favoring absorption and helping to maintain local effective concentrations. This retention for extended periods of time, in contrast with that of drops, that are\u0026ensp;either drained out too early or get trapped in oedema [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eMethods Rationale and Clinical\u0026ensp;Implications\u003c/h2\u003e\u003cp\u003eThe time-limited, time structured and effective therapeutic window of three 1-hour sessions used in\u0026ensp;this case. It balanced exposure to unnecessary antibiotics\u0026ensp;with efficacy. The timing\u0026ensp;of dressing changes permitted re-evaluation and canal cleansing with attention to patient comfort.\u003c/p\u003e\u003cp\u003eThis way of procedure could\u0026ensp;be a standard protocol, specifically, at the ENT outpatient clinic. It is also consistent with good antimicrobial\u0026ensp;stewardship, spanning use of therapy to effectively everything and leaving systemic antibiotics only when necessary. From a public health standpoint, promotion of clinician-directed short-course topical therapy may potentially\u0026ensp;lower drug resistance and treatment failures [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, restrictions need to\u0026ensp;be considered. This\u0026ensp;was an anecdotal report, and there was no microbiological confirmation. Common presenting features and early response\u0026ensp;were consistent with bacterial OE; however, culture-directed therapy might be helpful in future studies. Additionally, economic concerns and the availability of otomicroscopic facilities may limit the practicality of this approach in particular\u0026ensp;conditions.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eClinical Relevance Expanded\u003c/h3\u003e\n\u003cp\u003eBeyond patient-specific care, integration\u0026ensp;of clinician applied ear packing has impact on public health and practice. Its simplicity, low\u0026ensp;cost, and high success rate make it an attractive option, especially in the rural and resource-limited environment where topical drops (especially of the different classes with more durability) may not be readily accessible or used properly. The method also diminishes the reliance on self-treatment by the patient, an essential variable in determining the success of\u0026ensp;therapy of OE.\u003c/p\u003e\u003cp\u003eAdditionally, OE preventive education, especially for modifiable risk factors such as ear\u0026ensp;hygiene, excessive moisture, and trauma caused by the use of objects for ear cleaning is also important for the reduction of incidence rates. Addition of preventive counseling to the\u0026ensp;treatment visit offers a potential for benefit and reduction of future recurrence. It is widely considered that incorporation of\u0026ensp;patient education to mechanical and pharmacological interventions leads to better long-term resolution of OE [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Notably, environmental exposures, including freshwater swimming, have been recognized as predisposing risk factors for OE [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Further prospective trials may also investigate the economic\u0026ensp;effect of OE care in outpatient versus inpatient scenario, and highlight on wellness advocation by preventive protocols.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eShort-course hydrocortisone-oxytetracycline ear packing was successful in the management of uncomplicated otitis externa\u0026ensp;in this instance. This technique\u0026ensp;provided a rapid relief of symptoms, eliminated complications due to drops being taken by the patient and provided a more reproducible delivery of medication. This modality is mechanically superior and has better pharmacologic properties, so it deserves consideration as first-line therapy in canal obstruction or\u0026ensp;non-compliant patients.\u003c/p\u003e\u003cp\u003eIt would be also useful to have more evidence from randomized controlled studies,\u0026ensp;multi-center investigations and economic impact analysis to confirm the superiority of packing protocols over conventional drop method. There should be a commitment to improved clinician education into packing methods and patient education with more\u0026ensp;widespread adoption.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eOE Otitis Externa\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no external funding.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: Acute otitis externa. \u003cem\u003eOtolaryngol Head Neck Surg\u003c/em\u003e. 2014;150(1_suppl):S1\u0026ndash;S24. https://doi.org/10.1177/0194599813517083\u003c/li\u003e\n \u003cli\u003eRoland PS, Stroman DW. Microbiology of acute otitis externa. \u003cem\u003eLaryngoscope\u003c/em\u003e. 2002;112(7 Pt 1):1166\u0026ndash;1177. https://doi.org/10.1097/00005537-200207000-00004\u003c/li\u003e\n \u003cli\u003eBhatt R, Pokhrel R, Adhikari P, Neupane Y. A comparison of 10% ichthammol glycerine pack with steroid-antibiotic pack for relieving pain in cases of acute otitis externa. \u003cem\u003eJ Inst Med\u003c/em\u003e. 2009;31(1):7\u0026ndash;10.\u003c/li\u003e\n \u003cli\u003eAgius AM, Pickles JM, Burch KL. A prospective study of otitis externa. \u003cem\u003eClin Otolaryngol\u003c/em\u003e. 1992;17(2):150\u0026ndash;154. https://doi.org/10.1111/j.1365-2273.1992.tb01063.x\u003c/li\u003e\n \u003cli\u003eAbelardo E, Pope L, Rajkumar K, Greenwood R, Nunez DA. A double-blind randomized clinical trial of the treatment of otitis externa using topical steroid alone versus topical steroid-antibiotic therapy. \u003cem\u003eEur Arch Otorhinolaryngol\u003c/em\u003e. 2009;266(1):41\u0026ndash;45. https://doi.org/10.1007/s00405-008-0706-7\u003c/li\u003e\n \u003cli\u003eGray RF, Sharma A, Vowler SL. Relative humidity of the external auditory canal in normal and abnormal ears, and its pathogenic effect. \u003cem\u003eClin Otolaryngol\u003c/em\u003e. 2005;30(2):105\u0026ndash;111. https://doi.org/10.1111/j.1365-2273.2004.00950.x\u003c/li\u003e\n \u003cli\u003eWiegand S, Berner R, Schneider A, Lundershausen E, Dietz A. Otitis externa: Investigation and evidence-based treatment. \u003cem\u003eDtsch Arztebl Int\u003c/em\u003e. 2019;116(13):224\u0026ndash;230. https://doi.org/10.3238/arztebl.2019.0224\u003c/li\u003e\n \u003cli\u003eGuss J, Ruckenstein MJ. Infections of the external ear. In: Flint PW, Haughey BH, Lund VJ, et al. \u003cem\u003eCummings Otolaryngology \u0026ndash; Head and Neck Surgery\u003c/em\u003e. 6th ed. Philadelphia: Elsevier; 2015. p. 1944\u0026ndash;1949.\u003c/li\u003e\n \u003cli\u003eMalcolm P. Furunculosis. In: Gleeson M, editor. \u003cem\u003eScott-Brown\u0026rsquo;s Otorhinolaryngology, Head and Neck Surgery\u003c/em\u003e. 7th ed. Vol. 3. London: Edward Arnold; 2008. p. 3394\u0026ndash;3395.\u003c/li\u003e\n \u003cli\u003eSundstr\u0026ouml;m J, Jacobson K, Munck-Wikland E, Ringertz S. \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e in otitis externa. \u003cem\u003eArch Otolaryngol Head Neck Surg\u003c/em\u003e. 1996;122(8):833\u0026ndash;836. https://doi.org/10.1001/archotol.1996.01890200023004\u003c/li\u003e\n \u003cli\u003eSmith IM, Keay DG, Buxton PK. Contact hypersensitivity in patients with chronic otitis externa. \u003cem\u003eClin Otolaryngol\u003c/em\u003e. 1990;15(2):155\u0026ndash;158. https://doi.org/10.1111/j.1365-2273.1990.tb00449.x\u003c/li\u003e\n \u003cli\u003eMedina-Blasini Y, Sharman T. Otitis Externa. In: \u003cem\u003eStatPearls [Internet]\u003c/em\u003e. Treasure Island (FL): StatPearls Publishing; 2024. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556055/\u003c/li\u003e\n \u003cli\u003eWaitzman AA. Otitis Externa. \u003cem\u003eMedscape\u003c/em\u003e. Updated March 5, 2024. Available from: https://emedicine.medscape.com/article/994550-overview\u003c/li\u003e\n \u003cli\u003eSpringer GL, Shapiro ED. Fresh water swimming as a risk factor for otitis externa: a case-controlled study. \u003cem\u003eArch Environ Health\u003c/em\u003e. 1985;40(4):202\u0026ndash;206. https://doi.org/10.1080/00039896.1985.10545931\u003c/li\u003e\n \u003cli\u003eRussell JD, Donnelly M, McShane DP, et al. What causes acute otitis externa? \u003cem\u003eJ Laryngol Otol\u003c/em\u003e. 1993;107(10):898\u0026ndash;901. https://doi.org/10.1017/s0022215100124739\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Otitis externa, ear packing, hydrocortisone-oxytetracycline, topical therapy, short-course treatment","lastPublishedDoi":"10.21203/rs.3.rs-6698056/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6698056/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eBackground\u003c/em\u003e: To describe the efficacy of clinician-administered hydrocortisone-oxytetracycline ear packing over three sessions in resolving uncomplicated otitis externa (OE).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCase Presentation\u003c/em\u003e: A 34-year-old male with acute OE presented with severe pain, canal edema, and moderate discharge. Previous self-administered topical therapy had failed. Treatment involved three sessions of hydrocortisone-oxytetracycline-soaked ear packing over six days. Pain reduced by 40% at 48 hours and resolved completely by day 6. Edema and discharge progressively resolved, with full clinical recovery by day 6. No adverse events occurred.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusion\u003c/em\u003e: Structured ear packing offers a faster, safer alternative to conventional self-administered drops, ensuring rapid recovery and high patient comfort.\u003c/p\u003e","manuscriptTitle":"Successful Management of Uncomplicated Otitis Externa Using Short-Course Hydrocortisone-Oxytetracycline Ear Packing","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-25 08:50:36","doi":"10.21203/rs.3.rs-6698056/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ee31b1cc-134c-4540-ab21-6fd5ac9df172","owner":[],"postedDate":"August 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-29T06:54:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-25 08:50:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6698056","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6698056","identity":"rs-6698056","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}