What is the management for a 56-year-old female with recurrent otalgia and hearing loss in the ear, who has a history of tympanostomy tube (ear tube) insertion after swimming without earplugs?

From the Guidelines

For a 56-year-old female with recurrent ear pain and hearing loss after swimming with a history of tympanostomy tubes, immediate management should focus on treating the likely otitis externa (swimmer's ear) and preventing future episodes.

Management Approach

The management approach should include:

• Careful cleaning of the ear canal by gentle suction or dry mopping to remove debris
• Prescription of antibiotic ear drops containing ciprofloxacin 0.3% and dexamethasone 0.1%, 4 drops in the affected ear twice daily for 7-10 days, as recommended by the clinical practice guideline on tympanostomy tubes in children (update) 1
• Consideration of inserting a Pope ear wick to facilitate medication delivery if the ear canal is significantly swollen
• Pain management with acetaminophen 500-1000mg every 6 hours or ibuprofen 400-600mg every 6-8 hours as needed

Prevention of Recurrence

To prevent recurrence, the patient should be advised to:

• Use custom-fitted silicone ear plugs when swimming, as this can help prevent water from entering the ear canal
• Instill 2-3 drops of a solution of equal parts white vinegar and rubbing alcohol after water exposure to restore the ear canal's acidic environment, which inhibits bacterial growth while the alcohol helps dry the ear canal 1
• Avoid inserting cotton swabs or other objects into the ear canal, as this can push debris deeper and damage the ear canal skin

Rationale

The rationale for this approach is based on the latest clinical practice guidelines, which recommend against routine, prophylactic water precautions for children with tympanostomy tubes, but suggest that water precautions may be prudent for some individuals in defined clinical situations, such as those with recurrent or persistent otorrhea or ear discomfort during swimming 1. However, the guidelines also emphasize the importance of individualized care and consideration of the patient's specific needs and circumstances. In this case, the patient's history of recurrent ear pain and hearing loss after swimming suggests that preventive measures, such as using ear plugs and instilling vinegar and alcohol solution, may be beneficial in reducing the risk of future episodes.

From the FDA Drug Label

Ciprofloxacin and dexamethasone otic suspension is indicated for the treatment of infections caused by susceptible isolates of the designated microorganisms in the specific condition listed below: Acute Otitis Externa (AOE) in pediatric (age 6 months and older), adult and elderly patients due to Staphylococcus aureus and Pseudomonas aeruginosa.

The management for a 56-year-old female with recurrent otalgia and hearing loss in the ear, who has a history of tympanostomy tube (ear tube) insertion after swimming without earplugs, may involve the use of ciprofloxacin and dexamethasone otic suspension, if the symptoms are due to an infection caused by susceptible bacteria, such as Staphylococcus aureus or Pseudomonas aeruginosa.

• The recommended dosage regimen is: four drops instilled into the affected ear twice daily for seven days.
• It is essential to shake the bottle well before use and warm the suspension by holding the bottle in the hand for one or two minutes to avoid dizziness.
• The patient should lie with the affected ear upward and maintain this position for 60 seconds to facilitate penetration of the drops into the ear canal 2.
• If otorrhea persists after a full course of therapy, or if two or more episodes of otorrhea occur within six months, further evaluation is recommended to exclude an underlying condition, such as cholesteatoma, foreign body, or a tumor 2.

From the Research

Management of Recurrent Otalgia and Hearing Loss

• The patient's history of tympanostomy tube insertion and recurrent otalgia and hearing loss after swimming without earplugs suggests a possible correlation between water exposure and ear infections 3, 4, 5, 6.
• However, studies have shown that swimming without earplugs does not result in an increased incidence of middle ear infections 4, 5, 6.
• In fact, a prospective study found that the incidence of otorrhea/otalgia after swimming was not statistically significant between patients who swam with and without water protection 5.
• Another study found that the incidence of otorrhea was not different with or without prescription of ear protection during water exposure among children with tympanostomy tubes 6.

Treatment Options

• For patients with otitis media and associated otorrhea, current treatments include the administration of antibiotic or antibiotic/anti-inflammatory combination drops to the affected ear 7.
• A novel combination drug/hydrogel formulation for the treatment of otitis media/otorrhea has been developed, which releases both ciprofloxacin and dexamethasone over a 2-3 week period 7.
• This formulation has the potential to offer significant advantages over current treatments in use in the clinic, including improved patient compliance and reduced administration difficulties 7.

Recommendations

• Based on the available evidence, it is not necessary to avoid swimming or use water precautions for patients with tympanostomy tubes 3, 4, 5, 6.
• Patients with recurrent otalgia and hearing loss should be evaluated and treated for any underlying ear infections or other conditions that may be contributing to their symptoms 7.