What is the treatment for otitis externa?

Treatment of Otitis Externa

Topical antimicrobial eardrops are the first-line treatment for acute otitis externa (AOE), with oral antibiotics reserved only for specific circumstances such as infection extending beyond the ear canal. 1

First-Line Treatment

• Topical antimicrobial therapy is the mainstay of treatment for uncomplicated AOE 1

  • Effective against the most common pathogens: Pseudomonas aeruginosa (20-60%) and Staphylococcus aureus (10-70%) 1
  • Options include:
    • Quinolone-containing drops (e.g., ciprofloxacin with dexamethasone) 2
    • Aminoglycoside combinations (e.g., neomycin/polymyxin B/hydrocortisone) 3

• Dosing for topical therapy:

  • For ciprofloxacin/dexamethasone: Four drops into affected ear twice daily for seven days 2
  • For other preparations: Follow specific product instructions (typically 3-4 times daily) 3

• Aural toilet (cleaning of the ear canal) should be performed before administering drops to ensure medication reaches infected tissues 1

  • May include gentle suction, dry mopping, irrigation, or removal of obstructing debris 1

Pain Management

• Pain assessment and management is essential as AOE can cause severe pain 1
  • Recommend appropriate analgesics based on pain severity 1
  • Pain typically improves within 48-72 hours of starting treatment 1
  • Consider oral NSAIDs or acetaminophen for pain control 3

Special Considerations

• For patients with perforated tympanic membrane or tympanostomy tubes:

  • Use non-ototoxic preparations (avoid aminoglycosides like neomycin) 1
  • Quinolone-containing drops are preferred in these cases 3, 4

• For suspected fungal otitis externa (otomycosis):

  • Presents with pruritus and characteristic debris (white, black, gray, or colored) 1
  • Treat with topical antifungals (clotrimazole, miconazole) and debridement 5
  • Avoid antibacterial drops as they may promote fungal overgrowth 1

When to Use Systemic Antibiotics

• Oral antibiotics should be reserved for: 1, 3
  • Extension of infection beyond the ear canal
  • Patients with diabetes or immunocompromised status
  • When topical therapy cannot reach the infected area
  • Failure of topical therapy after reassessment

Treatment Algorithm

1. Initial assessment:

   • Confirm diagnosis of AOE (ear canal tenderness, edema, erythema) 1
   • Assess tympanic membrane status 1
   • Evaluate pain severity 1

2. For uncomplicated AOE with intact tympanic membrane:

   • Clean ear canal to remove debris 1
   • Prescribe topical antimicrobial therapy 1
   • Provide appropriate pain management 1

3. For AOE with perforated tympanic membrane or tubes:

   • Use non-ototoxic topical preparations (quinolones) 1, 4

4. For suspected fungal infection:

   • Topical antifungal treatment and debridement 5

5. Follow-up:

   • Reassess if no improvement in 48-72 hours 1
   • Consider culture and alternative therapy if infection persists 1

Common Pitfalls to Avoid

• Overuse of oral antibiotics - most cases respond well to topical therapy alone 1, 3
• Using ototoxic preparations when tympanic membrane integrity is compromised 1
• Inadequate pain management - AOE pain can be severe and requires appropriate analgesia 1
• Failure to remove debris before administering drops, reducing treatment efficacy 1
• Missing fungal infections - suspect if standard treatment fails 1, 5
• Not recognizing necrotizing otitis externa in diabetic or immunocompromised patients, which requires systemic therapy and possible surgical intervention 1

Patient Education

• Instruct patients on proper administration of eardrops:
  • Warm drops by holding bottle in hand for 1-2 minutes 2
  • Lie with affected ear upward when instilling drops 2
  • Maintain position for 60 seconds after instillation 2
• Inform patients that symptoms typically improve within 48-72 hours 1
• Advise completion of full course of therapy even if symptoms resolve early 1