What is the treatment for otitis externa in patients with ear (tympanostomy) tubes?

Treatment of Otitis Externa in Patients with Ear Tubes

For patients with otitis externa who have tympanostomy tubes, the clinician should prescribe a non-ototoxic topical antibiotic preparation, specifically a fluoroquinolone such as ofloxacin 0.3% or ciprofloxacin 0.2% administered twice daily for 7-10 days. 1, 2

Diagnosis and Initial Assessment

When evaluating otitis externa in patients with tympanostomy tubes, consider:

• Confirm the presence of tympanostomy tubes or tympanic membrane perforation
• Assess for signs of ear canal inflammation (erythema, edema, otorrhea)
• Evaluate pain severity (tenderness of tragus or pinna is a hallmark sign)
• Check for extension of infection beyond the ear canal

Treatment Algorithm

First-Line Treatment

1. Non-ototoxic topical antibiotic preparation 1, 2

   • Fluoroquinolone preparations are preferred:
     • Ofloxacin 0.3% otic solution: 5 drops (for children 1-12 years) or 10 drops (for patients ≥13 years) twice daily for 10 days 3
     • Ciprofloxacin 0.2% otic solution: twice daily for 7 days 2

2. Proper administration technique 1

   • Warm the solution by holding the bottle in hand for 1-2 minutes
   • Position patient with affected ear upward
   • For middle ear penetration, pump the tragus 4 times after instillation
   • Maintain position for 5 minutes

Ear Canal Preparation

• Aural toilet is essential before medication administration 1, 2

  • Clear inflammatory debris and obstructing cerumen
  • Use gentle suctioning or dry mop technique (blotting with cotton-tipped applicator)
  • Avoid irrigation in patients with tympanostomy tubes

• Consider ear wick placement if canal is severely edematous 1

  • Use compressed cellulose wick (expands when moistened)
  • Remove once ear canal edema subsides (usually within 24-72 hours)

Important Considerations

Avoid Ototoxic Preparations

• Aminoglycoside-containing preparations (e.g., neomycin/polymyxin B) should be avoided in patients with tympanostomy tubes due to potential ototoxicity 1, 2
• Prolonged or repetitive administration of ototoxic drops can cause severe hearing loss 1

When to Consider Systemic Antibiotics

Systemic antibiotics should be reserved for specific scenarios 2:

• Extension of infection outside the ear canal
• Presence of cellulitis of the pinna or adjacent skin
• Severe infection
• Immunocompromised patients
• Diabetic patients
• When adequate aural toilet or wick placement is not possible

Pain Management

• Assess pain severity and recommend appropriate analgesics 2
• Acetaminophen or NSAIDs for mild to moderate pain
• Consider short-term opioids for severe pain

Follow-up and Treatment Failure

• Reassess within 48-72 hours if no improvement 1, 2
• Consider fungal otitis externa if not responding to antibacterial treatment
• Evaluate for other conditions if symptoms persist

Clinical Evidence

Ofloxacin 0.3% otic solution has demonstrated clinical cure rates of >95% in children with otitis externa and 76% in children with otitis media in the presence of tympanostomy tubes 4. It is well-tolerated with minimal adverse events (primarily bitter taste in 5% of patients and pruritus in 2%) 4.

Fluoroquinolone preparations are the first choice for patients with tympanostomy tubes because they:

1. Are not ototoxic (unlike aminoglycosides)
2. Provide coverage against Pseudomonas aeruginosa and Staphylococcus aureus, the most common pathogens 5
3. Have been specifically approved for use in patients with non-intact tympanic membranes 4

Topical therapy is superior to systemic antibiotics for acute otitis media with tympanostomy tubes, with clinical cure rates of 77-96% versus 30-67% 2.