What is the best treatment for otitis externa?

Treatment of Otitis Externa

The best treatment for otitis externa is topical antibiotic-corticosteroid combination therapy, specifically a fluoroquinolone preparation with corticosteroid such as ciprofloxacin 0.3%/dexamethasone 0.1% (3-4 drops twice daily for 7 days). 1

First-Line Treatment Approach

Topical Therapy

• Preferred agent: Fluoroquinolone with corticosteroid (e.g., ciprofloxacin 0.3%/dexamethasone 0.1%)
  • Dosing: 3-4 drops twice daily for 7 days 1
  • Benefits: Provides both antimicrobial coverage and anti-inflammatory effects
  • Advantages over neomycin-containing products: No risk of ototoxicity if tympanic membrane is perforated 2

Proper Administration Technique

1. Position patient lying down with affected ear upward
2. Fill ear canal with prescribed drops
3. Maintain position for 3-5 minutes
4. Use gentle to-and-fro movement of the pinna or tragal pumping to help drops penetrate 3, 1
5. Have someone else administer drops when possible (improves adherence) 3

Ensuring Proper Drug Delivery

Ear Canal Preparation

• Clear obstructing debris before medication application using:
  • Gentle lavage with body-temperature water/saline
  • Suction removal
  • Dry mop technique (blotting with cotton-tipped applicator) 3, 1

Ear Wick Placement

• Indications: Edema preventing drop entry or inability to visualize tympanic membrane
• Material: Preferably compressed cellulose (expands when moistened)
• Duration: Remove once ear canal edema subsides (typically 24-72 hours) 3, 1
• Technique: Moisten wick with aqueous solution before first application of medication 3

Special Considerations

Perforated Tympanic Membrane

• Use only non-ototoxic preparations (fluoroquinolones)
• Avoid aminoglycoside-containing products (neomycin/polymyxin B) 1, 2

Diabetic or Immunocompromised Patients

• Avoid ear canal lavage as it may contribute to malignant otitis externa
• Consider atraumatic cleaning with aural suctioning under microscopic guidance 3, 1

Pain Management

• Mild to moderate pain: Acetaminophen or NSAIDs
• Severe pain: May require short-term opioids (48-72 hours) 1

Treatment Efficacy and Monitoring

Expected Response

• Most patients should show improvement within 48-72 hours 1
• Complete symptom resolution typically occurs within 7 days of treatment initiation 4

When to Suspect Treatment Failure

• No improvement after 48-72 hours
• Consider fungal infection (otomycosis) and alternative topical therapy 1

Prevention of Recurrence

Ear Care Instructions

• Keep ears dry
• Use ear protection when showering or washing hair
• Consider acidifying ear drops after swimming if recurrent episodes occur
• Avoid inserting foreign objects into the ear canal 1

Evidence Summary

• Topical treatments alone are effective for uncomplicated acute otitis externa 5
• Ofloxacin otic solution has demonstrated clinical cure rates >80% in adults and >95% in children 2
• Once-daily ofloxacin has shown equivalent efficacy to four-times-daily neomycin/polymyxin B/hydrocortisone 6
• Recent meta-analysis (2023) found no significant differences in cure rates between antiseptic, steroid, and antibiotic monotherapies 7

The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends topical therapy as first-line treatment, with systemic antibiotics reserved only for cases with infection extending beyond the ear canal or in immunocompromised patients 1.