What is the recommended treatment for otitis externa?

Treatment for Otitis Externa

Topical fluoroquinolone ear drops (such as ciprofloxacin 0.2% or ofloxacin 0.3%) are the recommended first-line treatment for uncomplicated otitis externa, with systemic antibiotics reserved only for specific circumstances when infection extends beyond the ear canal. 1

Diagnosis and Assessment

• Distinguish diffuse acute otitis externa from other causes of otalgia, otorrhea, and inflammation of the external ear canal 2
• Assess for modifying factors that may alter management:
  • Non-intact tympanic membrane or tympanostomy tubes
  • Diabetes
  • Immunocompromised state
  • Prior radiotherapy 2

First-Line Treatment: Topical Therapy

Recommended Topical Agents

• Fluoroquinolone ear drops (first-line):
  • Ciprofloxacin 0.2%: One single-dose container (0.25 mL) instilled into affected ear twice daily for 7 days 3
  • Ofloxacin 0.3%:
    • Children (6 months to 13 years): 5 drops once daily for 7 days (95% cure rate) 1, 4
    • Adults (≥13 years): 10 drops once daily for 7 days (91% cure rate) 1, 4, 5

Proper Administration Technique

• Warm solution by holding container in hands for 1-2 minutes to prevent dizziness 4, 3
• Patient should lie with affected ear upward during instillation
• Maintain position for 1-5 minutes after instillation
• For better penetration, pump the tragus 4 times by pushing inward 1

Pain Management

• Assess pain severity and provide appropriate analgesics 2
• Acetaminophen or NSAIDs are recommended for immediate pain relief 1
• Pain typically improves within 48 hours of starting treatment 1

When to Consider Systemic Antibiotics

Systemic antibiotics should NOT be prescribed as initial therapy for uncomplicated otitis externa 2. They should only be used when:

• Infection extends beyond the ear canal
• Patient has cellulitis of the pinna with systemic signs
• Patient has high fever (≥38.5°C/101.3°F)
• Patient is immunocompromised
• Patient has failed topical therapy after 72 hours 2, 1

Special Considerations

Non-intact Tympanic Membrane

• Use only non-ototoxic topical preparations (fluoroquinolones) 2, 1
• Avoid aminoglycoside-containing products due to potential ototoxicity 1, 6

Fungal Otitis Externa

• Consider azole antifungals (clotrimazole or miconazole) 1

Follow-up and Treatment Failure

• If no improvement within 48-72 hours, reassess to:
  • Confirm diagnosis
  • Exclude other causes
  • Consider culture-directed therapy 2
• Complete the full 7-day treatment course even if symptoms improve earlier 1

Prevention of Recurrence

• Avoid excessive moisture in ear canal
• Dry ears thoroughly after water exposure
• Consider prophylactic acidifying solutions after swimming
• Avoid inserting cotton-tipped swabs into ear canal 1

Common Pitfalls to Avoid

• Using neomycin-containing products as first-line therapy (risk of sensitization in 5-15% of patients) 1
• Prescribing systemic antibiotics for uncomplicated cases (leads to lower cure rates, more side effects, and antibiotic resistance) 2, 1
• Discontinuing treatment prematurely 1
• Using ear candles (no proven benefit, potential harm) 1
• Inadequate delivery of medication when ear canal is obstructed (may require aural toilet or wick placement) 2