What drops are used to treat otitis externa?

Treatment of Otitis Externa

For otitis externa, the first-line treatment is topical antibiotic drops containing fluoroquinolones (ciprofloxacin or ofloxacin), often combined with a corticosteroid like dexamethasone, administered for 7 days. 1, 2, 3

First-Line Treatment Options

Recommended Topical Medications:

1. Ciprofloxacin/Dexamethasone combination

   • Dosage: Four drops instilled into affected ear twice daily for 7 days 2
   • Particularly effective against the most common pathogens: Pseudomonas aeruginosa and Staphylococcus aureus
   • Cure rate of up to 90.9% 1

2. Ofloxacin 0.3% otic solution

   • Dosage:
     • Children (6 months to 13 years): Five drops once daily for 7 days 4
     • Adults (≥13 years): Ten drops once daily for 7 days 4
   • Clinical cure rate of 91% (95% in children, 88% in adults) 5
   • Comparable efficacy to neomycin/polymyxin B/hydrocortisone but without risk of ototoxicity 6

3. Ciprofloxacin 0.2% otic solution

   • Dosage: Contents of one single-dose container instilled into affected ear twice daily for 7 days 3

Proper Administration Technique

For optimal effectiveness, instruct patients to:

1. Warm the drops by holding the bottle in hand for 1-2 minutes (prevents dizziness from cold solution)
2. Lie with affected ear upward
3. Instill prescribed number of drops to fill ear canal
4. Maintain position for 3-5 minutes to facilitate penetration
5. Pump the tragus 4 times to help medication penetrate (especially important with tympanic membrane perforation) 1

Important Considerations

• Avoid aminoglycoside-containing drops (like neomycin) in patients with perforated tympanic membranes due to potential ototoxicity 1
• Ear wicks may be necessary for severe canal edema to ensure medication delivery 1
• Keep the ear dry during treatment using earplugs or cotton with petroleum jelly when showering 7
• Avoid ear canal manipulation with cotton swabs or other objects, which can worsen inflammation 1

Treatment Duration and Follow-up

• Continue treatment for at least 7 days, even if symptoms improve sooner, to prevent relapse 7
• If symptoms persist beyond 7 days:
  1. Reassess medication delivery technique
  2. Consider placing an ear wick if canal edema is present
  3. Consider switching to ofloxacin otic solution once daily for 7 days 1
  4. If still unresolved, consider adding oral antibiotics that cover Pseudomonas and Staphylococcus 1

Special Populations

• Diabetic or immunocompromised patients: Be vigilant for necrotizing (malignant) otitis externa, which requires urgent referral 1
• Patients with tympanic membrane perforation: Use ofloxacin 0.3% otic solution, which is approved for use with non-intact tympanic membranes 8

Prevention Strategies

• Dry ears thoroughly after swimming or bathing
• Consider acidifying ear drops before/after swimming
• Use ear plugs while swimming
• Avoid trauma to the ear canal 7

Common Pitfalls

• Inadequate treatment duration: Stopping treatment too early can lead to relapse
• Improper administration technique: Failure to maintain position after instillation reduces effectiveness
• Missing fungal infections: If bacterial treatment fails, consider fungal etiology
• Overlooking underlying conditions: Persistent symptoms may indicate foreign body, cholesteatoma, or tumor 2

By following these evidence-based recommendations, most cases of otitis externa can be effectively treated with topical therapy alone, avoiding unnecessary oral antibiotics and their associated risks.