What is the best treatment for an adult with ear tubes and discharge?

Best Treatment for Adults with Ear Tubes and Discharge

Topical antibiotic ear drops (ofloxacin or ciprofloxacin-dexamethasone) are the first-line treatment for adults with ear tubes and discharge, administered twice daily for up to 10 days. 1

Treatment Algorithm for Adults with Ear Tubes and Discharge

First-Line Treatment

• Use topical antibiotic ear drops (ofloxacin 0.3% or ciprofloxacin with or without dexamethasone) 1, 2
• Administer twice daily for up to 10 days 1, 2
• Clinical cure rates with topical therapy range from 77% to 96%, significantly higher than systemic antibiotics (30% to 67%) 1
• Topical therapy provides higher drug concentration at the infection site and better coverage of likely pathogens, especially Pseudomonas aeruginosa 1

Administration Technique

• Clean the ear canal of debris or discharge before administering drops 1
  • Use a cotton-tipped swab with hydrogen peroxide or warm water 1
  • Alternatively, use gentle suction with an infant nasal aspirator 1
• After instilling drops, "pump" the tragus (flap of skin in front of ear canal) several times to help the drops enter the ear tube 1
• For adults, use 10 drops per affected ear 2

Additional Measures

• Prevent water entry into the ear canal during treatment 1
  • Use cotton saturated with Vaseline to cover the opening during bathing or hair washing 1
  • Avoid swimming until the drainage stops 1
• Limit topical therapy to a single course of no more than 10 days to avoid fungal (yeast) infections of the ear canal 1

When to Consider Systemic Antibiotics

Systemic antibiotics are not first-line therapy but may be appropriate in specific situations:

• Cellulitis of the pinna or adjacent skin 1
• Concurrent bacterial infection elsewhere (e.g., sinusitis, pneumonia) 1
• Signs of severe infection (high fever, severe ear pain, toxic appearance) 1
• Persistent or worsening discharge despite topical antibiotic therapy 1
• When administration of ear drops is not possible due to discomfort or poor tolerance 1

Important Considerations

Pathogens

• Common pathogens in ear tube discharge include Pseudomonas aeruginosa, Staphylococcus aureus, and typical respiratory pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) 1, 2
• MRSA should be suspected in recurrent or recalcitrant cases 1

Advantages of Topical Therapy

• Avoids adverse events associated with systemic antibiotics (dermatitis, allergic reactions, GI upset, oral thrush) 1
• Reduces potential for increased antibiotic resistance 1, 3
• Only topical drops approved for use with tympanostomy tubes should be prescribed (quinolone drops with or without steroid) 1, 2
• Aminoglycoside-containing eardrops should be avoided due to potential ototoxicity 1

Follow-up

• If discharge continues for more than 7 days despite treatment, follow-up with an otolaryngologist is recommended 1
• Routine follow-up every 4-6 months is important to ensure tubes are functioning properly 1

Evidence Quality

The recommendations are based primarily on clinical practice guidelines from the American Academy of Otolaryngology-Head and Neck Surgery, with the most recent update in 2022 1. Multiple randomized controlled trials have demonstrated superior outcomes with topical antibiotic therapy compared to systemic antibiotics for treating ear discharge in patients with tympanostomy tubes 1, 4.