What is the treatment for otitis externa?

Treatment of Otitis Externa

The most effective treatment for otitis externa is topical fluoroquinolone eardrops (such as ciprofloxacin 0.2% or ofloxacin 0.3%) administered for 7 days, even if symptoms improve sooner. 1

First-Line Treatment Options

Topical Antimicrobial Options

• Fluoroquinolone eardrops:

  • Ciprofloxacin 0.2%: Instill into affected ear twice daily for 7 days 2
  • Ofloxacin 0.3%:
    • For patients ≥13 years: 10 drops once daily for 7 days
    • For children 6 months to 13 years: 5 drops once daily for 7 days 3
  • Clinical cure rates of 77-96% 1, with one study showing 91% cure rate (95% in children, 88% in adults) 4

• Cost-effective alternative: 2% acetic acid solution (white vinegar diluted with equal parts water)

  • Creates unfavorable environment for bacterial growth
  • Can be prepared at home
  • Note: Less effective than antibiotic/steroid drops when treatment extends beyond one week 1, 5

Proper Administration Technique

1. Warm the bottle by holding in hands for 1-2 minutes (prevents dizziness)
2. Position patient with affected ear upward
3. Instill prescribed number of drops
4. Maintain position for 5 minutes to facilitate penetration
5. Repeat for opposite ear if needed 1, 2, 3

Pain Management

• Acetaminophen or NSAIDs for initial pain relief until eardrops begin working
• Most patients feel better within 48-72 hours 1

Treatment Duration

• Continue treatment for full 7 days even if symptoms improve sooner
• Minimal symptoms typically present by day 7
• Patients can expect symptoms to last approximately 6 days after treatment begins 1, 5

Special Considerations

Severe or Complicated Infections

• For infections extending beyond the ear canal or in high-risk patients (diabetic, immunocompromised):
  • Consider oral antibiotics
  • Monitor closely for necrotizing (malignant) otitis externa 1

Fungal Otitis Externa

• Treat with azole antifungals (clotrimazole or miconazole) 1

Pregnancy Considerations

• Acetaminophen is considered safe for pain relief
• Avoid non-selective NSAIDs after 32 weeks of pregnancy 1

Prevention of Recurrence

• Manage underlying conditions
• Avoid moisture accumulation
• Consider prophylactic acidifying solutions
• Avoid inserting anything into the ear canal
• Keep ears dry during treatment 1

Important Caveats

• If eardrops are tasted, this may indicate a perforated eardrum - inform doctor immediately
• Avoid ear candles as they have no proven benefit and can cause harm
• Ciprofloxacin is contraindicated in persons with history of hypersensitivity to ciprofloxacin 1, 2
• For persistent symptoms beyond two weeks, consider treatment failure and initiate alternative management 5

While multiple treatment options exist, fluoroquinolone eardrops represent the most reliable first-line therapy with high cure rates and good safety profiles. The evidence shows that most topical treatments are equally effective, so factors like ototoxicity risk, contact sensitivity, resistance development, availability, cost, and dosing schedule may influence selection 5.