What is the treatment for otitis externa?

Treatment of Otitis Externa

Topical fluoroquinolone eardrops (e.g., ciprofloxacin 0.2% or ofloxacin 0.3%) administered once daily for 7 days are the first-line treatment for otitis externa, with clinical cure rates of 77-96%. 1

First-Line Treatment Options

Topical Antimicrobial Therapy

• Fluoroquinolone eardrops are highly effective:
  • Ciprofloxacin 0.2%: Instill twice daily for 7 days 2
    • Adults and children ≥13 years: One single-dose container (0.25 mL) per affected ear
  • Ofloxacin 0.3%: Instill once daily for 7 days 3
    • Children (6 months to 13 years): 5 drops (0.25 mL)
    • Adults and adolescents (≥13 years): 10 drops (0.5 mL)
  • Clinical cure rates of 91% have been demonstrated with once-daily ofloxacin regimens 4

Alternative Topical Options

• 2% Acetic acid solution (white vinegar diluted with equal parts water) is a cost-effective option for moderate cases 1
  • Note: Acetic acid is less effective than antibiotic/steroid drops when treatment extends beyond one week 5

Proper Administration Technique

1. Warm the bottle by holding it in hand for 1-2 minutes to prevent dizziness 2, 3
2. Position the patient with affected ear upward
3. Instill the drops into the ear canal
4. Maintain position for at least 1-5 minutes to facilitate penetration 2, 3
5. Perform aural toilet before medication administration to clear debris and obstructing cerumen 1

Pain Management

• Acetaminophen or NSAIDs for immediate pain relief until the infection is controlled 1
• Pain typically lasts approximately 6 days after treatment begins 5

Special Considerations

Causative Pathogens

• Most cases are caused by Pseudomonas aeruginosa and Staphylococcus aureus 1, 6
• Topical fluoroquinolones provide excellent coverage against these common pathogens 1

Treatment Duration

• Continue treatment for 7 days, even if symptoms improve sooner 1
• Patients with persisting symptoms beyond two weeks should be considered treatment failures and require alternative management 5

Special Cases

• Fungal otitis externa: Treat with azole antifungals (e.g., clotrimazole or miconazole) 1
• Necrotizing (malignant) otitis externa: Requires systemic antibiotics and close monitoring 1
• Chronic/recurrent cases: Investigate for underlying dermatologic conditions 1

Prevention Strategies

• Avoid excessive moisture in the ear canal
• Avoid trauma from inappropriate cleaning
• Consider prophylactic acidifying solutions after water exposure 1

Important Caveats

• Ototoxicity risk: Fluoroquinolones are considered safe for use even with non-intact tympanic membranes, unlike some other topical agents 7
• Treatment failures: If infection is not improved after one week, cultures may help guide further treatment 2
• Adverse effects: Most common include application site pain, ear pruritus, fungal ear superinfection, and headache (each in approximately 2-3% of patients) 2

Topical treatments alone are effective for uncomplicated acute otitis externa, with no consistent advantage shown for any specific drug among approved options 1, 5. The choice may be influenced by factors such as risk of ototoxicity, contact sensitivity, resistance development, availability, cost, and dosing schedule.