Treatment of Otitis Externa and Otitis Media
Otitis externa (OE) and otitis media (OM) require different treatment approaches, with topical antimicrobials being first-line for OE and systemic antibiotics often needed for OM. 1, 2
Otitis Externa Treatment
First-Line Treatment
- Topical antimicrobial therapy is the mainstay treatment for uncomplicated acute otitis externa, effective against common pathogens such as Pseudomonas aeruginosa and Staphylococcus aureus 2, 1
- Aural toilet (cleaning the ear canal) should be performed before administering drops to ensure medication reaches infected tissues 2, 3
- For intact tympanic membrane, ofloxacin 0.3% otic solution is recommended:
- Ciprofloxacin/dexamethasone combination (CIPRODEX®) is also effective: Four drops twice daily for seven days for patients 6 months and older 5
Pain Management
- Pain assessment and management is essential in OE, as pain can be severe 1
- Analgesics should be prescribed based on pain severity, with acetaminophen or NSAIDs for mild to moderate pain 1
- Pain typically improves within 48-72 hours of starting appropriate treatment 1, 2
Special Considerations
- For patients with perforated tympanic membrane or tympanostomy tubes, use non-ototoxic preparations only, such as quinolone drops 2, 1
- For diabetic or immunocompromised patients, monitor carefully for signs of necrotizing otitis externa and consider adding systemic antibiotics 1, 2
- For suspected fungal infection, use topical antifungal therapy and debridement 2, 6
When to Use Systemic Antibiotics
- Reserve oral antibiotics for specific circumstances 2:
- Extension of infection beyond the ear canal
- Patients with diabetes or immunocompromised status
- When topical therapy cannot reach the infected area or has failed
- Ciprofloxacin has shown effectiveness in treating malignant (necrotizing) external otitis 7
Otitis Media Treatment
Acute Otitis Media (AOM)
- Most cases of AOM resolve spontaneously with fewer patients requiring antibiotic treatment 1
- For AOM with tympanostomy tubes (TTO):
- Topical antibiotic therapy is superior to systemic antibiotics for TTO 1
- Clinical cure rates range from 77% to 96% with topical therapy compared to 30% to 67% with systemic antibiotics 1
- Recommended dosage for ofloxacin: Five drops twice daily for ten days in children 1-12 years old 4
- Recommended dosage for ciprofloxacin/dexamethasone: Four drops twice daily for seven days 5
Otitis Media with Effusion (OME)
- For persistent OME (3 months or longer), tympanostomy tube insertion may be considered 1
- Tympanostomy tubes are recommended for children with bilateral chronic OME and documented hearing difficulty 1
- Regular follow-up every 3-6 months is recommended until effusion resolves or significant hearing loss is detected 1
Chronic Suppurative Otitis Media
- For chronic suppurative otitis media with perforated tympanic membranes in patients 12 years and older:
Common Pitfalls to Avoid
- Overuse of oral antibiotics for uncomplicated otitis externa 2, 3
- Using ototoxic preparations when tympanic membrane integrity is compromised 2, 1
- Inadequate pain management 1
- Failure to remove debris before administering drops 2, 3
- Missing fungal infections, especially in patients with diabetes 2, 8
- Inappropriate drug selection for common pathogens (especially P. aeruginosa in OE) 2, 9
Administration Tips
- Warm the solution by holding the bottle in hand for 1-2 minutes before instillation to avoid dizziness 4, 5
- Patient should lie with affected ear upward during and for 5-60 seconds after instillation 4, 5
- For middle ear penetration, pump the tragus 4-5 times after instillation 4, 5
- Complete the full course of therapy even if symptoms resolve early 2, 9