Richtlijn: Otitis Externa - Kwaliteitskoepel

• AAO-HNSF 2006: The guideline of the AAO-HNSF discusses persisting AOE, meaning AOE that
does not dissolve despite topic treatment. If initial therapy does not respond within 48-72
hours, the ear should be reassessed. The clinician should inspect the ear, perform otoscopy
and or cleaning of the ear. A culture is advised.
• NHG-Standaard 2005: In case an ear wick soaked in topical medication is used, the acute
symptoms of AOE should dissolve within 24 hours. When the symptoms do not dissolve
within a week using eardrops , the ear should be reassessed and cleaned. This should be
repeated after another week of topical treatment. If however symptoms persist after three
weeks despite therapy, a culture is advised together with active screening for contact allergy.
After six weeks of continuing complaints of AOE a chronic middle ear disease should be
considered. Patients should be referred to an otorhinolaryngologist in case of fever or if they
have a compromised immune system or a combination of diabetes mellitus and general
weakness. When symptoms persist for more than five to six weeks or frequent episodes of
OE occur, referral to an otorhinolaryngologist is also advised.
• Cochrane review 2010: The review discusses treatment of acute otitis externa, persistent or
chronic otitis externa is not subject of the review. It is stated that symptoms of AOE last for
approximately six days once treatment has commenced. When symptoms do not resolve
within two weeks of treatment, the treatment is considered a failure and an alternative
therapy should be considered. The options for alternative therapy are not described. The
review mentions a specialist referral percentage of 3%. Surgical treatment for chronic
(recurrent) OE is not described.
Conclusies
Level of evidence 3
Observational
studies
Causes for persistent AOE are obstructed ear canal, poor patient adherence
to therapy and misdiagnosis (see table 2). In these cases the differential
diagnosis and possible modifying factors should be reassessed.
Overwegingen
Uit literatuur blijkt dat de meeste patiënten met AOE na twee weken hersteld zijn. In de derde week
treedt er weinig additioneel herstel op, daarom is een termijn van 3 weken gerechtvaardigd voordat
een AOE persisterend wordt genoemd (Van Balen 2003).
Aanbeveling
In het geval een acute otitis externa langer dan drie weken aanhoudt, ondanks therapie, dient de
differentiaal diagnose (1a) en factoren van invloed op het ziektebeloop/behandeling (1b) opnieuw in
overweging genomen te worden. Daarnaast dient een aantal misdiagnosen uitgesloten te worden
(zie tabel), de strategie wordt weergegeven in het onderstaande stroomschema.
35 Richtlijn Otitis Externa 2010
Nederlandse Vereniging voor Keel-Neus-Oorheelkunde en Heelkunde van het Hoofd-Halsgebied