What is the treatment for Acute Otitis Externa (AOE)?

From the Guidelines

The primary treatment for Acute Otitis Externa (AOE) involves topical antimicrobial therapy with acidifying agents, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1.

Key Considerations

• First-line treatment typically consists of antibiotic ear drops such as ciprofloxacin 0.3% or ofloxacin 0.3%, administered as 3-4 drops into the affected ear(s) twice daily for 7-10 days.
• For cases with significant inflammation, combination products containing an antibiotic plus a steroid (such as ciprofloxacin 0.3%/dexamethasone 0.1%) may provide faster symptom relief.
• Before applying drops, the ear canal should be gently cleaned of debris by a healthcare provider using suction or dry mopping.
• Patients should avoid getting water in their ears during treatment by using ear plugs or a cotton ball coated with petroleum jelly when showering.
• Pain management with acetaminophen or NSAIDs is often necessary in the first few days.
• For severe cases with significant ear canal swelling, an ear wick may be inserted to facilitate medication delivery.
• Oral antibiotics are rarely needed unless the infection has spread beyond the ear canal or in immunocompromised patients, as noted in the clinical practice guideline 1.

Special Considerations

• 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.
• Concurrent middle ear disease can modify treatment of AOE, and patients with a tympanostomy tube or tympanic membrane perforation may develop diffuse AOE because of purulent middle-ear secretions that enter the external ear canal.

Expected Outcomes

• AOE typically responds to treatment within 48-72 hours, with complete resolution in 7-10 days, as indicated in the patient information for topical therapy of acute otitis externa 1.
• The acidic environment created by these medications helps restore the normal ear canal environment and inhibits bacterial and fungal growth that thrives in the warm, moist conditions that typically cause this condition.

From the Research

Treatment for Acute Otitis Externa (AOE)

The treatment for AOE typically involves topical antibiotic therapy. Some of the commonly used treatments include:

• Ofloxacin otic solution: A study published in 2006 compared the efficacy, safety, and pain relief of once-daily ofloxacin otic solution versus neomycin sulfate/polymyxin B sulfate/hydrocortisone otic suspension four times a day in pediatric patients with OE, and found that once-daily ofloxacin otic solution was as effective and safe as neomycin sulfate/polymyxin B sulfate/hydrocortisone otic suspension given four times daily 2.
• Ciprofloxacin/dexamethasone otic suspension: A study published in 2004 compared the efficacy and safety of ciprofloxacin 0.3%/dexamethasone 0.1% otic suspension with that of neomycin 0.35%/polymyxin B 10,000 IU/mL/hydrocortisone 1.0% otic suspension in patients with AOE, and found that ciprofloxacin/dexamethasone otic suspension was clinically and microbiologically superior to neomycin/polymyxin B/hydrocortisone otic suspension 3.
• Neomycin/polymyxin B otic suspension: A study published in 2009 evaluated the synergic activity of neomycin in association with polymyxin B against the pathogens commonly responsible for otitis externa, and found that the polymyxin B/neomycin association showed clear synergic effects 4.

Considerations for Treatment

When choosing a treatment for AOE, it's essential to consider the following factors:

• The severity of the infection: Mild cases may be treated with topical antibiotics, while more severe cases may require oral antibiotics.
• The presence of underlying medical conditions: Patients with certain medical conditions, such as diabetes or compromised immune systems, may require more aggressive treatment.
• The risk of antibiotic resistance: A study published in 2004 found that the organisms most often causing otitis externa appear to be developing resistance to neomycin and polymyxin B but not to ofloxacin 5.
• The potential for side effects: Topical antibiotics can cause side effects such as ear discomfort, itching, or redness.

Recommendations for Treatment

Based on the available evidence, the following recommendations can be made:

• Topical antibiotic therapy is the first-line treatment for uncomplicated AOE 6.
• The choice of topical antibiotic should be based on the specific clinical situation and the potential for antibiotic resistance 5.
• Oral antibiotics may be considered for more severe cases or for patients with underlying medical conditions.