What is the treatment for a child with swimmer's ear (otitis externa) and tympanostomy tubes?

Treatment for Swimmer's Ear in Children with Tympanostomy Tubes

For children with swimmer's ear (otitis externa) who have tympanostomy tubes, topical antibiotic eardrops alone are the recommended first-line treatment, without oral antibiotics. 1

Understanding the Condition

When a child with ear tubes develops swimmer's ear, it presents a unique clinical situation because:

• The infection may involve both the external ear canal (otitis externa) and potentially the middle ear through the tube
• Water exposure is often the triggering factor, introducing pathogens like Pseudomonas aeruginosa and Staphylococcus aureus 1
• Drainage or discharge from the ear canal is the most common symptom

Treatment Algorithm

First-Line Treatment:

• Topical antibiotic eardrops only 1, 2
  • Ofloxacin 0.3% otic solution is FDA-approved for this purpose:
    • For children 1-12 years: Five drops (0.25 mL) twice daily for 10 days 2
    • For patients ≥13 years: Ten drops (0.5 mL) twice daily for 14 days 2
  • Ciprofloxacin-dexamethasone is an alternative option 1

Administration Technique:

1. Warm the solution by holding the bottle in hand for 1-2 minutes to prevent dizziness 2
2. Position the child with the affected ear upward
3. Instill the drops into the ear canal
4. Pump the tragus (flap of skin in front of ear canal) 4 times to help drops enter the tube 2
5. Maintain position for 5 minutes 2

Ear Canal Cleaning:

• Remove drainage with a cotton-tipped swab dipped in hydrogen peroxide or warm water 1
• Alternatively, use a cotton ball to absorb drainage or gently suction with an infant nasal aspirator 1
• Cleaning is essential for effective drug delivery 1

Water Precautions During Treatment

During active infection with drainage:

• Prevent water entry into the ear canal during bathing or hair washing
• Use cotton saturated with Vaseline to cover the ear canal opening 1
• Avoid swimming until drainage stops 1

When to Consider Oral Antibiotics

Oral antibiotics should be added only in specific circumstances:

• Child appears very ill or has high fever 1
• Concurrent bacterial infection requiring antibiotics (e.g., sinusitis, strep throat) 1
• Cellulitis of the pinna or adjacent skin 1
• Infection doesn't improve after 7 days of appropriate topical therapy 1
• Child is immunocompromised 1

Clinical Pearls and Pitfalls

Advantages of Topical Treatment:

• Higher drug concentration at infection site (up to 1000-fold higher than systemic therapy) 1
• Fewer systemic side effects (no gastrointestinal upset, allergic reactions, or oral thrush) 1
• Reduced risk of antibiotic resistance 1
• Better coverage of likely pathogens including Pseudomonas 3

Important Cautions:

• Only use drops specifically approved for tympanostomy tubes (ofloxacin or ciprofloxacin-dexamethasone) 1
• Avoid aminoglycoside-containing eardrops due to potential ototoxicity 1
• Limit topical therapy to a single course of no more than 10 days to prevent fungal external otitis 1

Follow-up:

• If drainage continues for more than 7 days, follow-up is needed 1
• Consider culture if infection persists despite appropriate treatment 1
• Routine follow-up every 4-6 months is recommended for all children with tubes 1

Prevention After Recovery

After the infection resolves, routine water precautions are generally not necessary for most children with tubes 1. However, water precautions may be beneficial in specific situations:

• Children with recurrent ear drainage 1
• When swimming in lakes or non-chlorinated pools 1
• For deep diving (more than 6 feet underwater) 1
• If the child experiences pain when water enters the ear canal 1