What is the recommended treatment for otitis externa in infants under 6 months?

Treatment of Otitis Externa in Infants Under 6 Months

For infants under 6 months with otitis externa, topical antibiotic therapy with quinolone drops (such as ofloxacin or ciprofloxacin) is the recommended first-line treatment, avoiding aminoglycoside-containing preparations due to potential ototoxicity. 1

Diagnosis Confirmation

Before initiating treatment, ensure proper diagnosis by looking for:

• Erythema and edema of the ear canal
• Ear pain (manifested as irritability, ear tugging in infants)
• Otorrhea (discharge from the ear canal)
• Tenderness upon manipulation of the pinna or tragus

Treatment Algorithm

First-line Treatment:

• Topical quinolone antibiotic drops (ofloxacin 0.3% or ciprofloxacin with or without dexamethasone)
  • Dosage: 5 drops into affected ear(s) once or twice daily for 7-10 days 2, 3
  • Clinical cure rates with topical therapy range from 77% to 96%, significantly higher than systemic antibiotics (30-67%) 1

Administration Technique:

1. Clean the ear canal of debris before administering drops
   • Use gentle suction with an infant nasal aspirator to remove visible secretions 1
   • Blot the canal opening to remove discharge
   • For adherent discharge, a cotton-tipped swab with hydrogen peroxide can be used carefully
2. Instill drops with the infant's head tilted to the side
3. Gently pump the tragus several times after instillation to aid delivery of medication 1
4. Keep the ear canal dry during treatment

Special Considerations:

• Tympanic membrane perforation: If present, only use quinolone drops specifically approved for use with perforated tympanic membranes (ofloxacin, ciprofloxacin) 1, 4
• Avoid aminoglycoside-containing eardrops (like neomycin) due to potential ototoxicity, especially if tympanic membrane integrity cannot be confirmed 1

When to Consider Systemic Antibiotics

Add oral antibiotics only when: 1

1. Cellulitis of the pinna or adjacent skin is present
2. Concurrent bacterial infection exists (e.g., pneumonia)
3. Signs of severe infection are present (high fever, severe pain, toxic appearance)
4. Otitis externa persists or worsens despite topical therapy

If systemic antibiotics are needed:

• Amoxicillin is the first-line choice for infants with intact tympanic membranes 1, 5
• Amoxicillin-clavulanate if beta-lactamase producing organisms are suspected 5

Follow-up and Treatment Failure

• Reassess after 48-72 hours if symptoms worsen or fail to improve 1
• If otorrhea persists beyond initial treatment:
  1. Re-clean the ear canal
  2. Consider culture of persistent drainage
  3. Consider referral to otolaryngology if symptoms persist beyond 2 weeks 1

Important Caveats

• Limit topical quinolone therapy to a single course of no more than 10 days to prevent fungal otitis externa 1
• While systemic quinolones are not approved for children under 14 years, topical quinolone drops are approved as they have minimal systemic absorption 1
• Topical antibiotic therapy avoids adverse events associated with systemic antibiotics (dermatitis, allergic reactions, GI upset, oral thrush) 1
• For infants with otitis media with tympanic membrane perforation (rather than otitis externa), different treatment considerations may apply 5