What is the recommended treatment for otitis externa?

Treatment of Otitis Externa

Topical antimicrobial therapy is the first-line treatment for uncomplicated acute otitis externa, delivering concentrations 100-1000 times higher than systemic therapy and effectively targeting common pathogens like Pseudomonas aeruginosa and Staphylococcus aureus. 1, 2

Initial Management

• Perform aural toilet to remove debris and enhance medication delivery before administering topical therapy 1, 3
• Cleaning methods include gentle suction, dry mopping, or irrigation with body-temperature water, saline, or hydrogen peroxide 3
• Place a wick in the ear canal if edema prevents drop entry or if most of the tympanic membrane cannot be visualized 3
• Prescribe topical antimicrobial preparations effective against common pathogens 1, 2

Medication Selection

• For intact tympanic membrane, options include:

  • Ciprofloxacin 0.2% solution: instill contents of one single-dose container twice daily for 7 days 4
  • Ofloxacin otic solution: 10 drops once daily for 7 days (for patients 13 years and older) or 5 drops once daily for 7 days (for patients 6 months to 13 years) 5
  • Other effective options include preparations containing aminoglycosides, polymyxin B, or low-pH antiseptics 2

• For non-intact tympanic membrane (perforation or tympanostomy tubes):

  • Use only non-ototoxic preparations such as quinolones (ciprofloxacin or ofloxacin) 1, 3, 2

• Adding a topical steroid to antimicrobial drops may help reduce inflammation and hasten pain relief 6, 7

Pain Management

• Assess pain severity and prescribe appropriate analgesics 1, 3
• Pain typically improves within 48-72 hours of starting appropriate treatment 1, 2
• For severe pain, consider short-term opioid-containing analgesics for the initial 48-72 hour period 6

Special Considerations

When to Use Systemic Antibiotics

• Systemic antibiotics should NOT be used as initial therapy for uncomplicated otitis externa 6, 1, 2
• Reserve oral antibiotics for specific circumstances:
  • Extension of infection beyond the ear canal
  • Patients with diabetes or immunocompromised status
  • When topical therapy cannot reach the infected area or has failed 1, 2

High-Risk Patients

• For diabetic or immunocompromised patients:
  • Monitor carefully for signs of necrotizing otitis externa 1, 3
  • Consider adding systemic antibiotics 1, 3
  • Avoid ear canal irrigation; use atraumatic cleaning with aural suctioning 3

Fungal Infections

• If fungal infection is suspected, especially in patients with diabetes or those who fail to respond to antibacterial therapy:
  • Use topical antifungal therapy and debridement 1, 3
  • Avoid antibacterial drops that may promote fungal overgrowth 1, 3

Patient Education

• Instruct patients on proper administration of eardrops 6, 1:
  • Lie down with the affected ear up
  • Fill the ear canal with drops
  • Remain in position for 3-5 minutes
  • Apply gentle to-and-fro movement of the ear to help drops penetrate
• Inform patients that symptoms typically improve within 48-72 hours 1, 2
• Complete the full course of therapy even if symptoms resolve early 1
• Keep the ear dry during treatment 6

Common Pitfalls to Avoid

• Overuse of oral antibiotics for uncomplicated cases 1, 2
• Using ototoxic preparations when tympanic membrane integrity is compromised 1, 3
• Inadequate pain management 1, 3
• Failure to remove debris before administering drops 1, 3
• Missing fungal infections, especially in patients with diabetes 1, 3
• Using ear candles, which have no proven efficacy and can cause harm 6