What is the recommended treatment for a 68-year-old patient with chronic otorrhea (discharge from the ear) bilaterally for 4 weeks, despite using Ciprodex (ciprofloxacin/dexamethasone), with a culture showing normal flora, and a computed tomography (CT) scan showing middle ear fluid and mastoid opacification, after bilateral ear tube placement for acute otitis media (middle ear infection)?

Management of Chronic Otorrhea After Tympanostomy Tube Placement

For a 68-year-old patient with chronic bilateral otorrhea persisting for 4 weeks despite Ciprodex use, ofloxacin otic solution should be used as first-line treatment, administered twice daily for 7-14 days. 1

Assessment of Current Situation

The patient presents with:

• Chronic bilateral otorrhea for 4 weeks
• Previous treatment with Ciprodex (ciprofloxacin/dexamethasone) without improvement
• Culture showing normal flora
• CT scan showing middle ear fluid and mastoid opacification
• History of bilateral ear tube placement for acute otitis media

This presentation suggests treatment failure with the initial antibiotic choice, requiring a change in management strategy.

Treatment Recommendations

First-Line Treatment:

• Ofloxacin otic solution:
  • Administer 10 drops in each affected ear twice daily (approximately 12 hours apart) 1, 2
  • Continue for 7-14 days, even if symptoms improve sooner 1
  • Ofloxacin is preferred due to its non-ototoxic properties and proven effectiveness 1

Administration Technique:

1. Warm the solution by holding the bottle in hand for 1-2 minutes to prevent dizziness 2
2. Have patient lie with affected ear upward
3. Instill drops into ear canal
4. Gently press the tragus 4 times in a pumping motion to facilitate penetration through the tube 2
5. Maintain position for 5 minutes
6. Repeat for the other ear

If No Improvement After 7 Days:

• Consider ear canal cleaning to remove debris that may be blocking medication delivery 1
• Obtain culture-directed therapy if not already done 1
• Consider alternative topical options:
  • Ciprofloxacin otic solution (without steroid component) 1
  • Different fluoroquinolone/corticosteroid combination 3

Rationale for Treatment Choice

Ofloxacin is recommended over continuing Ciprodex because:

1. The patient has already failed Ciprodex therapy
2. Ofloxacin provides excellent coverage against common pathogens including Pseudomonas aeruginosa, which is the most likely cause of persistent otorrhea after tympanostomy tube placement 1
3. Ofloxacin has demonstrated efficacy equal to oral antibiotics with fewer systemic side effects 4
4. Topical therapy delivers higher antibiotic concentrations to the infection site compared to oral options 3

When to Consider Systemic Antibiotics

Systemic antibiotics should be reserved for:

• Signs of severe infection
• Immunocompromised patients
• Concurrent bacterial infection elsewhere
• Evidence of cellulitis around the ear 1

In this case, the patient's age (68) may warrant consideration of systemic therapy if there are signs of mastoiditis or if topical therapy fails after 7-14 days, particularly given the CT findings of mastoid opacification.

Follow-up Recommendations

• Schedule follow-up in 7 days to assess treatment response
• If drainage persists beyond 7 days, continue treatment for up to 7 additional days
• Refer to an otolaryngologist if:
  • Drainage persists beyond 14 days of appropriate treatment
  • There are frequent recurrences
  • No response to treatment within 48-72 hours 1

Important Precautions

• Avoid contaminating the applicator tip 2
• Keep the ear dry during treatment
• Discontinue immediately if signs of allergic reaction occur 2
• Limit topical therapy to a single course of no more than 10-14 days 1

Potential Side Effects

Ofloxacin is generally well-tolerated with minimal side effects, which may include:

• Bitter taste (7% of patients)
• Discomfort upon application (7% of patients)
• Itching (1%)
• Earache (0.8%)
• Dizziness (0.4%) 2

This approach prioritizes topical therapy with a different antibiotic after failure of the initial treatment, which aligns with evidence-based recommendations for managing chronic otorrhea in patients with tympanostomy tubes.