How are ear infections treated?

Treatment of Ear Infections

Topical antimicrobials are the mainstay of treatment for acute otitis externa (AOE), while oral antibiotics should not be prescribed as initial therapy for uncomplicated cases. 1

Types of Ear Infections

• Otitis Externa (Swimmer's Ear): Infection of the external auditory canal skin and subdermis with acute inflammation and edema, presenting with ear pain, itching, or fullness, with or without hearing loss 1
• Acute Otitis Media (AOM): Bacterial infection of the middle ear, more common in children, characterized by sudden onset of fever, otalgia, and otorrhea 2
• Otitis Media with Effusion (OME): Presence of fluid in the middle ear without signs of acute infection 2
• Chronic Suppurative Otitis Media (CSOM): Persistent infection with drainage through a perforated tympanic membrane 2

Treatment of Acute Otitis Externa

First-Line Treatment

• Topical antimicrobial therapy is the treatment of choice for uncomplicated AOE 1
• Topical therapy delivers antimicrobial concentrations 100-1000 times higher than systemic therapy, making it more effective against potential pathogens 1
• Quinolone-containing eardrops (such as ciprofloxacin with dexamethasone) are recommended, especially for patients with non-intact tympanic membranes 3, 2
• Treatment should be continued for 7-10 days with clinical cure rates ranging from 77% to 96% 2

Administration Technique

1. Warm the bottle by rolling between hands for 1-2 minutes and shake well 3
2. Have patient lie down with affected ear facing upward 3
3. Gently pull the outer ear lobe upward and backward to allow drops to enter the ear canal 3
4. Instill prescribed number of drops (typically 4) 3
5. Remain with affected ear upward for at least 1 minute to allow medication to penetrate 3

Ensuring Proper Drug Delivery

• Aural toilet (cleaning the ear canal) is essential before administering drops if the canal is obstructed by debris 2
• Methods include:
  • Gentle lavage using body-temperature water, saline, or hydrogen peroxide 2
  • Physically removing debris with suction or dry mop technique (blotting with cotton-tipped applicator) 2
  • Using tissue spears to absorb discharge (see technique below) 2

Tissue Spear Technique

1. Twist (don't roll) the corner of tissue paper tightly 2
2. Break off about 1 inch of the top (too floppy to use) 2
3. Insert into ear with slight twist; stop when resistance is met 2
4. Leave for a minute to absorb discharge; remove slowly and discard 2
5. Repeat until spear comes out dry 2

For Severe Ear Canal Edema

• Ear wick placement may be necessary if edema prevents drop entry or if most of the tympanic membrane cannot be visualized 2
• Preferably use compressed cellulose wicks that expand when exposed to moisture, facilitating drug delivery and reducing ear canal edema 2
• After placement, moisten the wick with an aqueous solution before applying otic medication 2

Treatment of Acute Otitis Media

Management Approach

• Most cases of AOM resolve spontaneously without complications 2
• Symptomatic management of ear pain and fever is the mainstay of treatment 2
• Reserve antibiotics for children with severe, persistent, or recurrent infections 2

Surgical Interventions

• Ventilation (tympanostomy) tubes may be considered for recurrent AOM to prevent recurrences 2
• Adenoidectomy may also be considered for recurrent cases, though effectiveness remains debated 2

Treatment of Otitis Media with Effusion

• Management largely consists of watchful waiting 2
• Ventilation tubes primarily for children with chronic effusions and hearing loss, developmental delays, or learning difficulties 2

Special Considerations

Non-Intact Tympanic Membrane

• For patients with perforations or tympanostomy tubes, use non-ototoxic preparations (avoid aminoglycoside-containing drops) 1, 4
• Quinolone drops (e.g., ofloxacin, ciprofloxacin) are safe and effective in these patients 4

High-Risk Patients

• Patients with diabetes, immunocompromised states, or history of radiotherapy require special attention as they are susceptible to:
  • Otomycosis (fungal infection) 1, 5
  • Necrotizing otitis externa (invasive infection) 1, 2
• These patients may require longer treatment duration and closer monitoring 6

Fungal Infections

• Fungal involvement is uncommon in primary AOE but may occur after antibiotic treatment 1
• Antifungal therapy may be necessary for confirmed otomycosis 2
• For diabetic patients with otomycosis, blood sugar control is essential along with antifungal therapy 6

Treatment Response

• Improvement should be expected within 48-72 hours of initiating appropriate therapy 1
• If no improvement occurs within this timeframe, consider:
  • Treatment failure
  • Allergic contact dermatitis
  • Misdiagnosis 1

Prevention Strategies

• Remove obstructing cerumen
• Use acidifying ear drops before/after swimming
• Dry ear canal with a hair dryer after water exposure
• Use ear plugs while swimming 1