What is the treatment for otitis externa?

Treatment for Otitis Externa

First-line treatment for acute otitis externa is topical fluoroquinolone eardrops, specifically ciprofloxacin 0.2% or ofloxacin 0.3%, administered twice daily for 7 days. 1

Diagnosis and Assessment

Before initiating treatment, confirm the diagnosis by identifying:

• Ear pain and itching
• Canal edema and erythema
• Otorrhea (discharge)
• Tenderness with movement of the tragus or pinna (classic finding)

Treatment Algorithm

1. Topical Antimicrobial Therapy

First-line options:

• Ciprofloxacin 0.2% otic solution:

  • Dosing: Twice daily for 7 days 1, 2
  • Administration: Warm solution in hands for 1 minute, have patient lie with affected ear upward, instill drops, maintain position for 1 minute 2

• Ofloxacin 0.3% otic solution:

  • Dosing:
    • Children (6 months to 13 years): Five drops once daily for 7 days
    • Adults (≥13 years): Ten drops once daily for 7 days 3
  • Administration: Similar to ciprofloxacin

Alternative options (if tympanic membrane is intact):

• Acetic acid preparations
• Aminoglycoside-containing preparations (e.g., neomycin/polymyxin B/hydrocortisone) 1

2. Pain Management

• Assess pain severity
• Mild to moderate pain: Acetaminophen or NSAIDs
• Severe pain: Consider short-term opioids 1

3. Special Considerations

• Fungal otitis externa: Requires gentle debridement and topical antifungal therapy 1
• High-risk patients (diabetic, immunocompromised): Consider systemic antibiotics 1
• Perforated tympanic membrane: Use non-ototoxic preparations (fluoroquinolones preferred) 4

Evidence Analysis

The American Academy of Otolaryngology-Head and Neck Surgery recommends fluoroquinolone eardrops as first-line treatment 1. This is supported by FDA-approved indications for both ciprofloxacin 0.2% and ofloxacin 0.3% otic solutions 2, 3.

Clinical studies demonstrate high efficacy rates:

• Ciprofloxacin 0.2% achieves 70% clinical cure rates after 7 days of treatment 2
• Ofloxacin 0.3% once daily for 7 days achieves 91% cure rates (95% in children, 88% in adults) 5

Fluoroquinolones offer several advantages over aminoglycoside-containing preparations:

1. No ototoxicity risk if tympanic membrane is perforated 4
2. Simpler dosing regimens (once or twice daily vs. four times daily) 6
3. Comparable efficacy to traditional treatments 6, 7

Important Considerations and Pitfalls

• Verify tympanic membrane status before selecting treatment. If uncertain about membrane integrity, choose non-ototoxic fluoroquinolone preparations 4
• Warm the solution before administration to prevent dizziness 2, 3
• Monitor high-risk patients (diabetic, immunocompromised) closely for extension of infection beyond the ear canal 1
• Consider alternative diagnoses if dizziness is a prominent symptom, as this is not typical of uncomplicated otitis externa 1
• Discontinue treatment at first sign of hypersensitivity reaction 2
• Prolonged use may lead to overgrowth of resistant organisms including fungi 2
• Lack of response after one week should prompt culture to guide further treatment 2

Prevention Strategies

To prevent recurrent episodes, advise patients to:

• Keep ears dry
• Use ear protection when showering or washing hair
• Avoid cleaning ear canal with cotton-tip applicators 1