From the Guidelines
I strongly recommend treating this 56-year-old female for acute otitis externa (swimmer's ear) with topical antibiotic drops, specifically ciprofloxacin-dexamethasone otic drops (Ciprodex), administered 4 drops into the affected ear twice daily for 7 days, as this approach has been shown to be effective in managing acute tympanostomy tube otorrhea and improving quality of life 1. The clinical presentation of pain, hearing loss, and erythema around the tympanostomy tube after swimming strongly suggests otitis externa. The presence of the tympanostomy tube complicates management, as it creates a direct pathway between the external ear canal and middle ear. Ciprodex is preferred because it provides both antibiotic coverage against common pathogens (Pseudomonas aeruginosa and Staphylococcus aureus) and anti-inflammatory effects to reduce pain and swelling, as supported by the most recent clinical practice guideline on tympanostomy tubes in children (update) 1. Key considerations in managing this patient include:
- Keeping the ear dry during treatment by avoiding swimming and using a shower cap or cotton ball with petroleum jelly when bathing
- Using ear plugs when swimming in the future to prevent recurrence
- Monitoring for symptoms of more serious conditions like malignant otitis externa, especially given her age and fatigue symptoms
- Considering oral antibiotics or further evaluation if symptoms worsen or don't improve within 48-72 hours, as recommended by the clinical practice guideline on tympanostomy tubes in children (update) 1. It is essential to note that the use of topical antibiotic therapy, such as Ciprodex, has been shown to be effective in managing acute tympanostomy tube otorrhea, with superior outcomes compared to systemic oral antibiotics, as demonstrated in a systematic review of four RCTs 1. Additionally, the guideline recommends administration of topical antibiotic therapy should acute tube otorrhea occur, highlighting the importance of prompt treatment to prevent complications and improve quality of life 1.
From the FDA Drug Label
The recommended dosage regimen for the treatment of otitis externa is: For patients 13 years and older: Ten drops (0.5 mL, 1. 5 mg ofloxacin) instilled into the affected ear once daily for seven days. The solution should be warmed by holding the bottle in the hand for one or two minutes to avoid dizziness which may result from the instillation of a cold solution. The patient should lie with the affected ear upward, and then the drops should be instilled This position should be maintained for five minutes to facilitate penetration of the drops into the ear canal.
The management for a 56-year-old female with recurrent otalgia and hearing loss, who has a previous tympanostomy tube placement, presents with general fatigue and erythema around the tube site, without fever, after swimming without earplugs, may involve the use of ofloxacin (OTIC) for otitis externa, with a recommended dosage of ten drops (0.5 mL, 1.5 mg ofloxacin) instilled into the affected ear once daily for seven days 2.
- The patient should lie with the affected ear upward and maintain this position for five minutes to facilitate penetration of the drops into the ear canal.
- It is also recommended to warm the solution by holding the bottle in the hand for one or two minutes to avoid dizziness.
- However, the presence of a tympanostomy tube and the specific symptoms presented may require additional evaluation and management.
From the Research
Management of Recurrent Otitis Media
The patient, a 56-year-old female with a history of tympanostomy tube placement, presents with recurrent otalgia, hearing loss, general fatigue, and erythema around the tube site after swimming without earplugs. The management of this condition can be informed by the following points:
- Antibiotic Selection: The choice of antibiotic is crucial in the treatment of otitis media. Studies have shown that ofloxacin otic solution is effective in treating purulent otorrhea in children with tympanostomy tubes 3, 4. Amoxicillin/clavulanate is also a commonly used antibiotic for the treatment of respiratory tract infections, including otitis media 5.
- Topical vs. Systemic Antibiotics: Topical ofloxacin has been shown to be as effective as systemic amoxicillin/clavulanate in treating acute otitis media in children with tympanostomy tubes 4. This suggests that topical antibiotics may be a viable option for the treatment of otitis media in patients with tympanostomy tubes.
- Empiric Antibiotic Selection: The selection of empiric antibiotics should be based on the most likely pathogens associated with the infection, as well as local surveillance and susceptibility data 6. In the case of otitis media, the most common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
- Predictors of Broad-Spectrum Antibiotic Prescribing: The prescribing of broad-spectrum antibiotics is influenced by various factors, including physician specialty, geographic region, and patient characteristics such as race and insurance status 7. These factors should be taken into account when selecting empiric antibiotics.
Treatment Options
Based on the available evidence, the following treatment options may be considered:
- Topical Ofloxacin: Topical ofloxacin otic solution may be effective in treating purulent otorrhea in patients with tympanostomy tubes 3, 4.
- Amoxicillin/Clavulanate: Amoxicillin/clavulanate may be considered as an alternative to topical ofloxacin, especially in cases where the patient has a history of resistant organisms 5.
- Empiric Antibiotic Therapy: Empiric antibiotic therapy should be based on the most likely pathogens associated with the infection, as well as local surveillance and susceptibility data 6.