From the Guidelines
The most appropriate pharmacologic treatment for this child is neomycin, polymyxin B, and hydrocortisone drops, as this combination medication is the first-line treatment for acute otitis externa (swimmer's ear), which this child is experiencing 1. The clinical presentation strongly suggests this diagnosis, with ear pain, canal inflammation, tragal tenderness, and a history of swimming. The combination drops provide antimicrobial coverage against the common pathogens in otitis externa (Pseudomonas aeruginosa and Staphylococcus aureus) while the hydrocortisone component helps reduce inflammation and discomfort.
Some key points to consider in the treatment of acute otitis externa include:
- The drops should be applied 3-4 times daily for 7-10 days after gently cleaning the ear canal 1.
- The child should avoid swimming and keep the ear dry during treatment.
- This topical therapy is preferred over oral antibiotics because the infection is localized to the ear canal, and the intact tympanic membrane indicates that this is not a middle ear infection.
- The absence of fever and the presence of specific findings like tragal tenderness further support the diagnosis of otitis externa rather than otitis media.
- It's also important to note that the use of topical antibiotic therapy avoids adverse events associated with systemic antibiotics, including dermatitis, allergic reactions, gastrointestinal upset, and increased antibiotic resistance 1.
- The child's age and the fact that they do not have any underlying conditions that may affect the treatment, such as diabetes or immunocompromised state, support the use of topical therapy as the first-line treatment 1.
From the FDA Drug Label
The recommended dosage regimen for the treatment of otitis externa is: For pediatric patients (from 6 months to 13 years old): Five drops (0.25 mL, 0.75 mg ofloxacin) instilled into the affected ear once daily for seven days. The child’s symptoms, such as ear pain, jaw pain, and fullness, along with the presence of inflammation of the ear canal and tragal erythema with tenderness to palpation, are consistent with otitis externa. Given the child's age (9 years old) and the diagnosis of otitis externa, the most appropriate pharmacologic treatment is ofloxacin drops.
- The dosage for pediatric patients (from 6 months to 13 years old) is five drops (0.25 mL, 0.75 mg ofloxacin) instilled into the affected ear once daily for seven days 2.
From the Research
Pharmacologic Treatment for Otitis Externa
The child's symptoms, such as ear pain, jaw pain, and fullness, along with the presence of inflammation of the ear canal and tragal erythema, are consistent with a diagnosis of otitis externa. The most appropriate pharmacologic treatment for this child would be:
- Topical antimicrobials or antibiotics, such as ofloxacin otic solution or ciprofloxacin/dexamethasone otic suspension, which are effective against the common pathogens associated with otitis externa, including Pseudomonas aeruginosa and Staphylococcus aureus 3, 4, 5, 6.
- Neomycin/polymyxin B/hydrocortisone otic suspension is also an option, but its effectiveness may be limited due to increasing resistance to neomycin and polymyxin B 7.
Treatment Options
The following treatment options are available:
- Ofloxacin otic solution (0.3%) once daily for 7-10 days 3.
- Ciprofloxacin/dexamethasone otic suspension (0.3%/0.1%) 3-4 drops twice daily for 7 days 6.
- Neomycin/polymyxin B/hydrocortisone otic suspension 3-4 drops four times daily for 7-10 days 3, 4.
Considerations
When choosing a treatment, consider the following factors:
- The integrity of the tympanic membrane, which is intact in this child 4.
- The potential for adverse effects, such as ototoxicity associated with neomycin 3.
- The convenience of once-daily versus multiple-daily dosing 3.
- The cost and availability of the treatment options.
Based on the evidence, the most appropriate answer is: d. ofloxacin drops