Can neomycin (antibiotic) polymyxin (antibiotic) ear drops be used in a child with tympanostomy (ear) tubes?

Neomycin-Polymyxin Ear Drops in Children with Tympanostomy Tubes

Neomycin-polymyxin ear drops should NOT be used in children with tympanostomy tubes due to potential ototoxicity risk. Instead, fluoroquinolone ear drops (such as ofloxacin or ciprofloxacin) should be used as first-line treatment for otorrhea in children with ear tubes. 1, 2

Safety Concerns with Neomycin-Containing Products

• Neomycin is an aminoglycoside antibiotic with known ototoxicity potential when exposed to the middle ear through a non-intact tympanic membrane
• The FDA drug label for neomycin otic preparations indicates risk of allergic cross-reactions and potential systemic effects 3
• Repeated doses of neomycin ear drops (≥2 prescriptions) have been associated with an increased risk of sensorineural hearing loss in children with non-intact tympanic membranes 4
• Aminoglycoside-containing preparations should be avoided due to ototoxicity risk 2

Recommended Treatment for Otorrhea in Children with Ear Tubes

First-Line Treatment:

• Topical antibiotic ear drops only (without oral antibiotics) for uncomplicated acute tympanostomy tube otorrhea 1
• Fluoroquinolone ear drops (ofloxacin or ciprofloxacin) are preferred because:
  • They are not ototoxic
  • They provide excellent coverage against common pathogens including Pseudomonas aeruginosa
  • They have demonstrated equivalent efficacy to neomycin-containing products 5
  • They are specifically approved for use with non-intact tympanic membranes 2

Administration Tips:

1. Clean the ear canal of debris or discharge before administering drops
   • Blot the canal opening or use an infant nasal aspirator
   • Clean dry crust with cotton-tipped swab and hydrogen peroxide (safe with tubes) 1
2. Have the child lie with the affected ear up
3. Fill the ear canal with prescribed drops
4. "Pump" the tragus several times after instillation to help medication enter the middle ear 1, 2

Special Circumstances for Systemic Antibiotics

Systemic antibiotics (with or without topical therapy) should be reserved for:

• Cellulitis of the pinna or adjacent skin
• Concurrent bacterial infection (e.g., sinusitis, pneumonia)
• Signs of severe infection (high fever, severe otalgia, toxic appearance)
• Persistent or worsening otorrhea despite topical therapy
• Immunocompromised patients 1

Water Precautions

• Routine, prophylactic water precautions are NOT necessary for children with tympanostomy tubes 1
• Ear plugs or water avoidance are only needed in specific situations:
  • Pain/discomfort when water enters ear canal
  • Active drainage from the ear
  • Swimming more than 6 feet underwater
  • Swimming in non-chlorinated water
  • Head dunking in bathtub 1

Monitoring and Follow-up

• Most children should experience improvement within 48-72 hours of starting appropriate treatment 2
• If otorrhea persists beyond 7 days or symptoms worsen despite treatment, reassessment is needed 2
• Consider culture of persistent drainage to guide further therapy 1

While one older study suggested short-term use of neomycin-containing drops might be safe 6, more recent evidence and guidelines clearly recommend against using these products when safer and equally effective alternatives (fluoroquinolone drops) are available 1, 2, 7.