What are the treatment options for otitis externa and otitis media?

Treatment Options for Otitis Externa and Otitis Media

For otitis externa, first-line treatment is topical fluoroquinolone eardrops such as ciprofloxacin 0.2% or ofloxacin 0.3% administered twice daily for 7 days, while otitis media treatment depends on type and chronicity, with acute cases often requiring oral antibiotics and chronic cases potentially benefiting from tympanostomy tubes. 1

Otitis Externa Treatment

First-line Treatment

• Topical antibiotic therapy is superior to systemic antibiotics for otitis externa
  • Fluoroquinolone preparations are preferred:
    • Ciprofloxacin 0.2% or ofloxacin 0.3% twice daily for 7 days 1
    • For pediatric patients (6 months to 13 years): 5 drops once daily for 7 days
    • For patients ≥13 years: 10 drops once daily for 7 days 2

Proper Administration Technique

1. Warm the solution by holding the bottle in hand for 1-2 minutes to prevent dizziness
2. Position patient with affected ear upward
3. Instill drops and maintain position for 5 minutes 2
4. Clean ear canal of debris before administration using gentle suctioning or cotton-tipped swab with hydrogen peroxide 3

Alternative Treatments

• Acetic acid preparations can be used if tympanic membrane is intact, but are less effective than antibiotic/steroid drops beyond one week of treatment 1, 4
• Steroid-only drops (betamethasone dipropionate 0.05%) have shown effectiveness, particularly for non-infected cases 5

For Fungal Otitis Externa

• Azole antifungals (clotrimazole or miconazole) twice daily for 7-14 days
• Thorough cleaning and debridement of fungal debris is essential 1

When to Use Systemic Antibiotics

Systemic antibiotics are indicated when:

1. Cellulitis of the pinna or adjacent skin is present
2. Concurrent bacterial infection exists
3. Signs of severe infection are present (high fever, severe otalgia, toxic appearance)
4. Infection persists or worsens despite topical therapy 3, 1
5. Patient has diabetes, is immunocompromised, or has history of radiotherapy 1

Otitis Media Treatment

Acute Otitis Media

• Pain management is essential: acetaminophen or NSAIDs for mild to moderate pain 1
• Antibiotics shorten symptoms and duration of middle ear effusion 1
• For acute otitis media with tympanostomy tubes:
  • Topical therapy is superior to systemic antibiotics with clinical cure rates of 77-96% vs. 30-67% 3
  • Recommended regimen: 5 drops of ofloxacin 0.3% twice daily for 10 days (ages 1-12 years) 2

Chronic Suppurative Otitis Media

• For perforated tympanic membranes in patients ≥12 years:
  • 10 drops of ofloxacin 0.3% twice daily for 14 days 2
• Proper administration includes pumping the tragus 4 times to facilitate penetration into the middle ear 2

Otitis Media with Effusion (OME)

• Tympanostomy tubes are recommended for:
  • Persistent OME for ≥3 months
  • Bilateral chronic OME with documented hearing difficulty
  • Unilateral or bilateral chronic OME with symptoms attributable to OME 3
• Tympanostomy tubes reduce treatment failures by 38% compared to controls 1
• Tympanostomy tubes with adenoidectomy reduces treatment failures by 53% 1

Prevention Strategies

• Keep ears dry
• Use ear protection when showering or washing hair
• Avoid ear canal cleaning with cotton-tip applicators 1
• For patients with tympanostomy tubes, prevent water entry during periods of active otorrhea 3

Treatment Failures

• Reassess patients who fail to respond within 48-72 hours 1
• Consider fungal infection if not responding to antibacterial treatment
• For persistent otitis externa, consider underlying skin disease 6
• For necrotizing (malignant) otitis externa, aggressive treatment with systemic antibiotics is required, particularly in diabetic or immunocompromised patients 1, 6

Comparative Efficacy

• Ciprofloxacin has shown superior efficacy compared to oxytetracycline-polymyxin B-hydrocortisone combination for otitis externa, particularly for Pseudomonas aeruginosa infections 7
• Once-daily ofloxacin for 7 days has demonstrated 91% cure rates in otitis externa with 96% bacterial eradication 8