What is the treatment for otitis externa?

Treatment of Otitis Externa

For uncomplicated otitis externa, topical fluoroquinolone ear drops (such as ciprofloxacin 0.2% or ofloxacin 0.3%) should be used as first-line treatment, administered twice daily for 7 days. 1, 2, 3

First-Line Treatment Options

Topical Antibiotics

• Fluoroquinolone ear drops are recommended due to:
  • Excellent coverage against common pathogens (Pseudomonas aeruginosa and Staphylococcus aureus)
  • High clinical cure rates (77-96%)
  • Lower risk of contact sensitivity compared to neomycin-containing products 1

Specific Regimens:

• Ciprofloxacin 0.2% otic solution:

  • Dosage: Instill contents of one single-dose container into affected ear twice daily for 7 days
  • Clinical cure rate: 70% after 7-day treatment 2

• Ofloxacin 0.3% otic solution:

  • For adults and children ≥13 years: 10 drops once daily for 7 days
  • For children 6 months to 13 years: 5 drops once daily for 7 days
  • Clinical cure rate: 91% overall (95% in children, 88% in adults) 3, 4

Administration Technique

1. Warm the solution by holding the container in hands for 1-2 minutes
2. Position patient with affected ear upward
3. Instill drops into ear canal
4. Maintain position for 5 minutes to facilitate penetration
5. Repeat for opposite ear if necessary 2, 3

Adjunctive Measures

Pain Management

• Acetaminophen or NSAIDs for immediate pain relief until infection is controlled 1

Aural Toilet

• Gentle cleaning of the ear canal may be beneficial to remove debris
• Can be performed by dry mopping or gentle suction 5, 1

Water Precautions

• Avoid swimming or water activities during treatment
• Keep ear canal dry with earplugs or cotton with petroleum jelly when showering 1

Special Considerations

Fungal Otitis Externa

• Use topical azole antifungals (clotrimazole or miconazole) instead of antibiotics 1

Necrotizing (Malignant) Otitis Externa

• Requires systemic antibiotics and close monitoring 1

Prevention of Recurrence

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

Common Pitfalls to Avoid

1. Using neomycin-containing products as first-line therapy - can cause sensitization in 5-15% of patients with chronic otitis externa 1
2. Inserting cotton-tipped swabs into the ear canal - can cause trauma and worsen infection 1
3. Using oral antibiotics for uncomplicated cases - lower cure rates (30-67%), more systemic side effects, and contributes to antibiotic resistance 1
4. Discontinuing treatment prematurely - complete the full 7-day course even if symptoms improve earlier 2
5. Using ear candles - no proven benefit and can cause harm 1

Treatment Failure

If infection does not improve after one week of therapy, consider:

• Obtaining cultures to guide further treatment 2
• Evaluating for contact dermatitis from topical medications
• Assessing for underlying conditions requiring additional management 1