What is the treatment for otitis media (middle ear infection) and otitis externa (swimmer's ear)?

Treatment of Otitis Media and Otitis Externa

For otitis media (middle ear infection) and otitis externa (swimmer's ear), treatment should be targeted to the specific condition, with antibiotics reserved for appropriate cases and topical therapy as the mainstay for external ear infections. 1

Acute Otitis Media (Middle Ear Infection)

Diagnosis

• Diagnosis requires acute onset of symptoms, middle ear effusion, and physical evidence of middle ear inflammation (such as bulging tympanic membrane) 1, 2
• Symptoms typically include ear pain (otalgia), irritability, and fever 2

Treatment Algorithm

1. Pain Management

   • Begin with adequate analgesia as the first step in management 1, 2
   • Options include acetaminophen or ibuprofen for pain relief 1

2. Antibiotic Decision-Making

   • Children under 2 years: Antibiotic therapy recommended for all cases 2, 3
   • Children 2 years and older with mild symptoms: Observation without antibiotics is an option (watchful waiting) 1, 2
   • Immediate antibiotics indicated for:
     • Temperature ≥39°C
     • Bilateral otitis media
     • Otorrhea (ear discharge)
     • Severe symptoms
     • Children who appear toxic
     • Immunocompromised patients
     • Craniofacial abnormalities
     • Uncertain follow-up 3

3. First-Line Antibiotic

   • High-dose amoxicillin (80-90 mg/kg/day) is the drug of choice for non-allergic patients 1, 2
   • Treatment duration typically 10 days for children under 2 years; 5-7 days may be sufficient for older children 1

4. For Penicillin-Allergic Patients

   • Trimethoprim-sulfamethoxazole or macrolides are alternatives 4
   • However, resistance rates should be considered 1

5. Treatment Failure

   • If symptoms persist after 48-72 hours of initial therapy, patient should be reassessed 1
   • Second-line therapy: Amoxicillin-clavulanate if initial treatment was amoxicillin 1, 2
   • For patients who fail amoxicillin-clavulanate or oral cephalosporins, intramuscular ceftriaxone (50 mg/kg) may be used 1
   • For multiple treatment failures, tympanocentesis should be considered for culture and susceptibility testing 1

Special Populations

• Children with Down syndrome or cleft palate have higher risk of otitis media and complications 1
• These children may benefit from more aggressive management and earlier referral to specialists 1

Otitis Media with Effusion (OME)

• Defined as middle ear fluid without signs of acute infection 1, 2
• Antibiotics, decongestants, and nasal steroids are NOT recommended as they do not hasten fluid clearance 2
• Watchful waiting is appropriate for most cases 1
• Consider tympanostomy tubes for:
  • Persistent effusions with hearing loss
  • Developmental delays
  • Speech/language difficulties 2

Otitis Externa (Swimmer's Ear)

Diagnosis

• Infection of the external auditory canal with symptoms including otalgia, tenderness, and ear discharge 1, 5
• More common in adults, with lifetime prevalence of approximately 10% 1, 5

Treatment

1. Cleansing the Ear Canal

   • Gentle removal of debris and discharge is important before medication application 1, 5

2. Topical Therapy

   • Topical antibiotics with or without corticosteroids are the treatment of choice 1, 5
   • Ofloxacin otic solution 0.3% is FDA-approved for otitis externa:
     • Adults and children ≥13 years: 10 drops once daily for seven days
     • Children 6 months to 13 years: 5 drops once daily for seven days 6
   • Corticosteroid-containing preparations help reduce swelling, erythema, and secretions 5

3. For Perforated Tympanic Membrane

   • Use only non-ototoxic topical preparations to avoid hearing damage 1
   • Ofloxacin is approved for use in perforated tympanic membranes 6

4. Systemic Antibiotics

   • Oral antibiotics are indicated only when:
     • Infection spreads beyond the ear canal
     • Patient has poorly controlled diabetes
     • Patient is immunocompromised 1, 5

5. Follow-up

   • Reassess patients who fail to respond to initial therapy within 48-72 hours 1

Tympanostomy Tube Otorrhea

• For acute otorrhea in patients with tympanostomy tubes, topical antibiotic therapy is more effective than oral antibiotics 1
• Ofloxacin otic solution is indicated for acute otitis media in children with tympanostomy tubes:
  • 5 drops twice daily for ten days (ages 1-12 years) 6

Chronic Suppurative Otitis Media

• For perforated tympanic membranes with chronic drainage:
  • Topical antibiotics are the treatment of choice 1
  • Ofloxacin otic: 10 drops twice daily for fourteen days (age ≥12 years) 6
• Systemic antibiotics should be reserved for cases with systemic symptoms or complications 1

Important Cautions

• Accurate diagnosis is essential to reduce overdiagnosis and antibiotic overuse 1
• Middle ear effusion commonly persists for weeks to months after acute otitis media resolution 7
• For otitis externa, ensure proper administration technique: warm drops before instillation, position affected ear upward, and maintain position for 5 minutes 6
• Necrotizing otitis externa (malignant) is a serious complication requiring urgent treatment, particularly in diabetic or immunocompromised patients 5