What is the recommended management for otitis externa?

Management of Otitis Externa

The recommended first-line treatment for uncomplicated otitis externa is topical fluoroquinolone ear drops (such as ciprofloxacin 0.2% or ofloxacin 0.3%) once daily for 7 days, which have demonstrated superior clinical cure rates (77-96%) compared to oral antibiotics (30-67%). 1

Initial Treatment Approach

Ear Canal Cleaning

• Gentle cleaning of the ear canal to remove debris
  • Use dry mopping or gentle suction
  • Avoid cotton-tipped swabs which can cause trauma and worsen infection 1

Topical Antimicrobial Therapy

1. First-line treatment:

   • Fluoroquinolone ear drops (ciprofloxacin 0.2% or ofloxacin 0.3%)
   • Dosage:
     • Adults and children ≥13 years: 10 drops once daily for 7 days
     • Children 6 months to 13 years: 5 drops once daily for 7 days 1, 2
   • Complete the full 7-day course even if symptoms improve earlier 1

2. For fungal otitis externa:

   • Azole antifungals (clotrimazole or miconazole) 1

3. For necrotizing (malignant) otitis externa:

   • Systemic antibiotics and close monitoring 1

Pain Management

• Acetaminophen or NSAIDs for immediate pain relief
• Pain typically improves within 48 hours of starting treatment 1

Treatment Considerations

Efficacy Evidence

• Ofloxacin 0.3% otic solution once daily for 7 days has demonstrated:
  • 91% overall clinical cure rate (95% in children, 88% in adolescents/adults)
  • 96% bacterial eradication rate 2
  • Comparable efficacy to neomycin/polymyxin B/hydrocortisone administered four times daily 3

Important Contraindications and Cautions

• Avoid neomycin-containing products as first-line therapy

  • Can cause sensitization in 5-15% of patients with chronic otitis externa 1
  • Risk of ototoxicity with tympanostomy tubes or perforated tympanic membrane 4

• Avoid oral antibiotics for uncomplicated cases

  • Lower cure rates
  • More systemic side effects
  • Contributes to antibiotic resistance 1

• Avoid ear candles

  • No proven benefit and can cause harm 1

Prevention of Recurrence

• Keep ears dry
  • Use earplugs or cotton with petroleum jelly when showering
  • Thoroughly dry ears after water exposure
• Avoid swimming during treatment
• Consider prophylactic acidifying solutions after water exposure 1

Special Considerations

• Some evidence suggests that topical steroids may help resolve symptoms more quickly 5
• Dexamethasone otic preparations are FDA-approved for steroid-responsive inflammatory conditions of the external auditory meatus, such as allergic otitis externa 6
• Some research suggests that an aminoglycoside antibiotic may not convey significant benefit in this condition, but this contradicts current guidelines 7

Treatment Algorithm

1. Uncomplicated otitis externa:

   • Gentle ear canal cleaning
   • Topical fluoroquinolone ear drops once daily for 7 days
   • Pain management as needed

2. If fungal etiology suspected:

   • Topical azole antifungal

3. If severe or spreading infection:

   • Consider systemic antibiotics
   • Close monitoring
   • Possible referral to specialist