What is the treatment for otitis externa?

Treatment of Acute Otitis Externa

The mainstay treatment for acute otitis externa (AOE) is topical antimicrobial therapy, which should be preceded by aural toilet to ensure medication reaches infected tissues. 1

First-Line Treatment Approach

• Topical antimicrobial therapy is the cornerstone of treatment for uncomplicated AOE, delivering antimicrobial concentrations 100-1000 times higher than systemic therapy against common pathogens like Pseudomonas aeruginosa and Staphylococcus aureus 1, 2
• Aural toilet (gentle suction, dry mopping, irrigation, or removal of obstructing debris) should be performed before administering drops to ensure medication reaches infected tissues 1
• Topical quinolone preparations (ofloxacin, ciprofloxacin) are effective first-line options:
  • For patients ≥13 years: 10 drops of ofloxacin 0.3% once daily for 7 days 3
  • For pediatric patients (6 months to 13 years): 5 drops of ofloxacin 0.3% once daily for 7 days 3
  • Ciprofloxacin 0.2% otic solution: contents of one single-dose container twice daily for 7 days 4

Pain Management

• Pain assessment and management is essential in AOE, as pain can be intense and severe due to the proximity of the highly sensitive periosteum to the ear canal skin 5
• Analgesic treatment should be based on pain severity:
  • Mild to moderate pain: acetaminophen or nonsteroidal anti-inflammatory drugs 5
  • Moderate to severe pain: combination of NSAIDs with opioids (e.g., oxycodone, hydrocodone) 5
• Pain typically improves within 48-72 hours of starting appropriate treatment 1

Special Considerations

Non-Intact Tympanic Membrane

• For patients with perforated tympanic membranes or tympanostomy tubes, use non-ototoxic preparations such as quinolones (ofloxacin, ciprofloxacin) 1
• Avoid aminoglycoside-containing preparations (e.g., neomycin) due to potential ototoxicity 1

Fungal Otitis Externa

• Suspect fungal infection if patient fails to respond to initial topical antibacterial therapy 5
• Treatment includes debridement plus topical antifungal therapy 5
• Avoid antibacterial drops as they may promote further fungal overgrowth 5

High-Risk Patients

• Patients with diabetes, immunocompromised status, or history of radiotherapy require special attention due to increased risk of complications 1, 2
• Monitor these patients more carefully for signs of necrotizing otitis externa 1

When to Use Systemic Antibiotics

• Oral antibiotics should NOT be used as initial therapy for uncomplicated AOE 1, 2
• Reserve oral antibiotics for specific circumstances:
  • Extension of infection beyond the ear canal 1
  • Patients with diabetes or immunocompromised status 1
  • When topical therapy cannot reach the infected area or has failed 1
  • Patients with concurrent middle ear disease 5
  • Patients after radiotherapy 5

Expected Outcomes and Follow-up

• Patients should expect improvement within 48-72 hours of initiating appropriate topical therapy 1, 2
• Clinical cure rates with topical therapy range from 65-90% within 7-10 days 5
• If no improvement occurs within 48-72 hours, consider:
  • Treatment failure
  • Allergic contact dermatitis
  • Misdiagnosis 2

Common Pitfalls to Avoid

• Overuse of oral antibiotics for uncomplicated cases (approximately 20-40% of patients receive unnecessary oral antibiotics) 1, 2
• Using ototoxic preparations when tympanic membrane integrity is compromised 1
• Inadequate pain management 5, 1
• Failure to remove debris before administering drops 1
• Missing fungal infections, especially in patients who fail to respond to antibacterial therapy 5, 1
• Selecting oral antibiotics with inadequate coverage against Pseudomonas aeruginosa 1

Patient Education

• Instruct patients on proper administration of eardrops:
  • Warm the solution by holding the bottle in hand for 1-2 minutes to avoid dizziness 3, 4
  • Lie with the affected ear upward when instilling drops 3, 4
  • Maintain this position for 1-5 minutes to facilitate penetration of drops 3, 4
• Complete the full course of therapy even if symptoms resolve early 1
• Prevention strategies to reduce recurrence:
  • Remove obstructing cerumen
  • Use acidifying ear drops before/after swimming
  • Dry the ear canal with a hair dryer
  • Use ear plugs while swimming 2