What is the recommended treatment for otitis externa?

Treatment of Otitis Externa

The first-line treatment for otitis externa is topical fluoroquinolone ear drops (such as ciprofloxacin 0.2% or ofloxacin 0.3%) administered for 7 days, with cure rates of 77-96%. 1

First-Line Treatment Approach

• Topical fluoroquinolone ear drops:

  • Adults and children ≥13 years: Ofloxacin 0.3% otic solution, 10 drops once daily for 7 days 1, 2
  • Children 6 months to 13 years: Ofloxacin 0.3% otic solution, 5 drops once daily for 7 days 1, 2

• Administration technique:

  1. Warm the solution by holding the bottle in hand for 1-2 minutes to prevent dizziness 2
  2. Position patient with affected ear upward
  3. Instill drops
  4. Pump the tragus 4 times to facilitate penetration 1
  5. Maintain position for 5 minutes 2
  6. Complete the full 7-day course even if symptoms improve earlier 1

Pain Management

• Acetaminophen or NSAIDs for immediate pain relief until the infection is controlled 1
• Pain typically improves within approximately 48 hours of starting treatment 1

Monitoring and Follow-up

• If no improvement after 72 hours of therapy, reevaluate to determine next course of treatment 1
• If patient fails to respond after 7 days, refer to an otolaryngologist for:
  • Microscopic examination
  • Culture of ear drainage
  • Evaluation for complications or alternative diagnoses 1

Special Considerations

Specific Types of Otitis Externa

• Fungal otitis externa: Azole antifungals (e.g., clotrimazole or miconazole) 1
• Necrotizing (malignant) otitis externa: Systemic antibiotics and close monitoring 1
  • Ciprofloxacin has shown 96.4% clinical cure rate for malignant external otitis 3

Treatment Efficacy

• Once-daily ofloxacin otic solution for 7 days has demonstrated 91% overall cure rate:
  • 95% in children
  • 88% in adolescents/adults 4
• 68% of patients are cured within 7 days of starting treatment 4

Important Cautions and Contraindications

• Avoid:
  • Neomycin-containing products as first-line therapy (can cause sensitization in 5-15% of patients with chronic otitis externa) 1
  • Cotton-tipped swabs in the ear canal (can cause trauma and worsen infection) 1
  • Oral antibiotics for uncomplicated cases (lower cure rates, more systemic side effects, contributes to antibiotic resistance) 1
  • Ear candles (no proven benefit, can cause harm) 1

Prevention of Recurrence

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

Clinical Pearls

• Ofloxacin otic solution is particularly safe when there is an undiagnosed tympanic membrane perforation due to its lack of ototoxicity 5
• Less frequent dosing (once daily) with ofloxacin likely encourages greater patient adherence compared to more frequent regimens 5
• Pseudomonas aeruginosa (62%) and Staphylococcus aureus (13%) are the most common pathogens in otitis externa 4, 6