What is the treatment for swimmer's ear (otitis externa) with a perforated tympanic membrane?

From the Guidelines

For swimmer's ear (otitis externa) with no intact tympanic membrane, the recommended treatment is using non-ototoxic antibiotic ear drops like ciprofloxacin-dexamethasone (Ciprodex) or ofloxacin (Floxin Otic), typically 4 drops in the affected ear twice daily for 7-10 days, as they are safe for use with a perforated eardrum and effective against common bacteria causing the infection 1.

Key Considerations

• The presence of a perforated tympanic membrane requires careful management to avoid ototoxicity, and the use of non-ototoxic ear drops is crucial 1.
• Before applying drops, gently cleaning the ear canal of debris using a bulb syringe with warm saline or diluted white vinegar solution (1:1 with water) is recommended 1.
• Keeping the ear dry during treatment by avoiding swimming and using earplugs or cotton balls coated with petroleum jelly during showers is essential to prevent further infection 1.
• Pain can be managed with acetaminophen or ibuprofen, and it is important to discuss with the doctor which pain medicines are best for the patient 1.

Treatment Approach

• The use of fluoroquinolone drops, such as ciprofloxacin-dexamethasone (Ciprodex) or ofloxacin (Floxin Otic), is effective because they target the common bacteria causing swimmer's ear while the steroid component reduces inflammation and swelling, allowing better penetration of the medication into the infected area without risking inner ear damage through the perforated membrane 1.
• It is also important to note that patients with diabetes, an immunocompromised state, or both require special consideration because they are susceptible to otomycosis and necrotizing otitis externa, which may present similar to AOE but require different management 1.

Important Precautions

• The use of aminoglycoside-containing drops should be avoided in patients with a perforated eardrum, as they can cause hearing damage 1.
• Patients with a history of radiotherapy, tympanostomy tubes, or perforated tympanic membrane may require modified treatment approaches, and it is essential to discuss these factors with the doctor to determine the best course of 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. For patients 13 years and older: Ten drops (0.5 mL, 1. 5 mg ofloxacin) instilled into the affected ear once daily for seven days. Chronic Suppurative Otitis Media with perforated tympanic membranes The recommended dosage regimen for the treatment of chronic suppurative otitis media with perforated tympanic membranes in patients 12 years and older is: Ten drops (0.5 mL, 1. 5 mg ofloxacin) instilled into the affected ear twice daily for fourteen days.

Treatment for Swimmer's Ear with No Intact Membrane:

• For patients with no intact membrane, the dosage regimen is similar to that of Chronic Suppurative Otitis Media with perforated tympanic membranes.
• The recommended dosage is Ten drops (0.5 mL, 1.5 mg ofloxacin) instilled into the affected ear twice daily for fourteen days for patients 12 years and older 2.
• It is essential to warm the solution by holding the bottle in the hand for one or two minutes and to pump the tragus 4 times by pushing inward to facilitate penetration into the middle ear.

From the Research

Swimmer's Ear with No Intact Membrane Treatment

• The study 3 discusses various ear problems in swimmers, including acute diffuse otitis externa (swimmer's ear), which is the most common ear problem in swimmers.
• However, the study 3 does not specifically address the treatment of swimmer's ear with no intact membrane.
• It does mention that traumatic eardrum perforations may occur during water skiing or scuba diving and present with symptoms of hearing loss, otalgia, otorrhea, tinnitus, and vertigo.
• According to the study 3, tympanoplasty might be needed if the perforations do not heal spontaneously, but it does not provide information on the treatment of swimmer's ear with a perforated eardrum.
• The study 3 also notes that sudden sensorineural hearing loss and some degree of vertigo may occur after diving because of rupture of the round or oval window membrane, but it does not provide guidance on treating swimmer's ear in this context.