What is the treatment for external otitis?

Treatment of External Otitis

The first-line treatment for acute otitis externa (AOE) is topical antimicrobial therapy, not systemic antibiotics, delivered with proper aural toilet to ensure medication reaches the infected tissues. 1, 2

Initial Assessment and Management

• Assess for complications or special considerations:

  • Check for perforated tympanic membrane or tympanostomy tubes 2
  • Evaluate for extension beyond ear canal or immunocompromised status 2
  • Assess pain severity 1

• For uncomplicated AOE, follow this approach:

  • Perform aural toilet to remove debris and ensure medication delivery 1
  • Prescribe topical antimicrobial preparation (with or without steroid) 1
  • Provide pain management based on severity 1

Topical Antimicrobial Options

• Quinolone preparations (e.g., ciprofloxacin 0.2%, ofloxacin 0.3%):

  • Safe for use with perforated tympanic membranes 2
  • Administer twice daily for 7 days 3
  • Clinical cure rates of approximately 70% after 7 days of treatment 3

• Aminoglycoside/polymyxin B combinations with steroid:

  • Effective but potentially ototoxic 2
  • Should be avoided if tympanic membrane integrity is uncertain 1

Proper Administration Technique

• Warm the solution by holding the container in hands for at least 1 minute to minimize dizziness 3
• Patient should lie with affected ear upward during instillation 3
• Maintain position for at least 1 minute to facilitate penetration 3
• Complete the full 7-day course even if symptoms improve sooner 2

Special Situations

• For perforated tympanic membrane/tympanostomy tubes:

  • Use non-ototoxic preparations (quinolones) 1
  • Avoid aminoglycoside-containing preparations due to potential ototoxicity 2

• For extension beyond ear canal or immunocompromised patients:

  • Consider systemic antibiotics active against Pseudomonas aeruginosa and Staphylococcus aureus in addition to topical therapy 4

• For diabetic patients:

  • Monitor closely for necrotizing otitis externa 1
  • Consider systemic therapy if high risk for complications 1

Follow-up and Treatment Failure

• Reassess within 48-72 hours if no improvement 4
• Consider treatment failure if symptoms persist beyond 7 days 2
• Reasons for treatment failure may include:
  • Inadequate drug delivery due to canal obstruction 4
  • Poor adherence to therapy 4
  • Incorrect diagnosis 4
  • Fungal infection 4
  • Contact dermatitis from topical agents 4

Common Pitfalls to Avoid

• Unnecessary use of systemic antibiotics for uncomplicated cases 1
• Using ototoxic preparations when tympanic membrane integrity is compromised 1
• Inadequate pain management 1
• Failure to remove debris before administering drops 1
• Missing fungal infections, especially in treatment failures 1
• Patients tend to overadminister ear drops when pain is greatest and underadminister as symptoms resolve 4

Patient Education Points

• Symptoms typically improve within 48-72 hours of starting treatment 1
• Complete the full course of therapy (7 days) even if symptoms resolve early 2
• Proper drop administration is crucial for treatment success 1
• Return for reassessment if symptoms don't improve within 48-72 hours 4
• Avoid water exposure during treatment 5