What is the treatment for otitis externa?

Treatment of Otitis Externa

Topical fluoroquinolone ear drops (such as ciprofloxacin 0.2% or ofloxacin 0.3%) are the first-line treatment for uncomplicated otitis externa, with cure rates of 77-96%. 1

Diagnostic Features

• Rapid onset (within 48 hours) in the past 3 weeks
• Symptoms: otalgia (ear pain), itching, fullness
• Signs: tenderness of tragus/pinna, ear canal edema/erythema
• Predominantly bacterial in origin (98% of cases in North America) 1

Treatment Algorithm

1. Uncomplicated Otitis Externa

• First-line therapy: Topical fluoroquinolone ear drops

  • Ofloxacin 0.3% once daily for 7 days (5 drops for children <13 years, 10 drops for adolescents/adults) 1, 2
  • Ciprofloxacin 0.2% ear drops 1
  • Continue treatment for 7 days even if symptoms improve earlier 1

• Pain management:

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

2. Fungal Otitis Externa (Otomycosis)

• Topical azole antifungals (clotrimazole or miconazole) 1

3. Severe/Complicated Cases

• Oral antibiotics (amoxicillin is standard first-line)
• Treatment duration: 7-10 days 1

4. Necrotizing (Malignant) Otitis Externa

• Systemic antibiotics
• Close monitoring
• Consider specialist referral 1

Special Considerations

High-Risk Patients

• Diabetes: Higher risk for severe infections, fungal otitis externa, delayed healing, and progression to necrotizing otitis externa
• Immunocompromised patients: More aggressive treatment approach
• Post-radiation patients: Require delicate debridement, higher risk of poor healing 1

Contraindications and Cautions

• Neomycin-containing products: Not recommended as first-line therapy due to sensitization risk (5-15% of patients with chronic otitis externa) 1, 3

  • Evidence shows declining susceptibility to neomycin and polymyxin B among pathogens causing otitis externa 3
  • Fluoroquinolones maintain better susceptibility patterns 3

• Perforated eardrum: Requires careful product selection to avoid ototoxicity

Prevention of Recurrence

• Avoid excessive moisture in ear canal
• Dry ears thoroughly after water exposure
• Avoid inappropriate cleaning (e.g., cotton-tipped swabs)
• Consider prophylactic acidifying solutions after water exposure 1

Common Pitfalls to Avoid

1. Using oral antibiotics for uncomplicated cases: Results in lower cure rates, more systemic side effects, and contributes to antibiotic resistance 1

2. Premature discontinuation of treatment: Complete the full 7-day course even if symptoms improve earlier 1

3. Using cotton-tipped swabs: Can cause trauma and worsen infection 1

4. Ear candles: No proven benefit and potential for harm 1

5. Inadequate pain management: Pain is a significant symptom requiring prompt attention 1

Efficacy Evidence

• Once-daily ofloxacin otic solution (0.3%) for 7 days has shown 91% cure rates overall (95% in children, 88% in adolescents/adults) 2
• Ofloxacin otic solution once daily is as effective as neomycin/polymyxin B/hydrocortisone administered four times daily, with comparable pain relief but without the ototoxicity risk associated with neomycin 4
• Topical antimicrobials containing steroids are significantly more effective than placebo drops 5