What is the treatment for otitis externa?

Treatment of Otitis Externa

The first-line treatment for uncomplicated acute otitis externa is topical antimicrobial therapy, which delivers medication concentrations 100-1000 times higher than systemic therapy and effectively targets common pathogens like Pseudomonas aeruginosa and Staphylococcus aureus. 1, 2

Initial Management

• Perform aural toilet to remove debris and enhance medication delivery before administering drops, using gentle suction, dry mopping, or irrigation with body-temperature water, saline, or hydrogen peroxide 3, 2
• Place a wick in the ear canal if edema prevents drop entry or if most of the tympanic membrane cannot be visualized, to facilitate drug delivery and reduce ear canal edema 3, 2
• Prescribe topical antimicrobial preparations effective against common pathogens, such as those containing aminoglycosides, polymyxin B, quinolones, or low-pH antiseptics 1, 2
• Adding a topical steroid to antimicrobial drops may help reduce inflammation and hasten pain relief 2, 4

Proper Administration of Ear Drops

• Warm the solution by holding the bottle in hand for 1-2 minutes to avoid dizziness from instilling cold solution 5, 6
• Patient should lie with affected ear upward, then instill drops to fill the ear canal 3, 5
• Maintain this position for 3-5 minutes to facilitate penetration of drops into the ear canal 3, 5
• Use gentle to-and-fro movement of the pinna or tragal pumping to eliminate trapped air and ensure filling 3, 2

Medication Selection

• For intact tympanic membrane: Neomycin/polymyxin B/hydrocortisone combinations are reasonable first-line therapy 4, 2
• For non-intact tympanic membrane (perforation or tympanostomy tubes): Use only non-ototoxic preparations such as quinolones (ciprofloxacin or ofloxacin) 1, 2
• Ciprofloxacin otic solution 0.2%: Instill contents of one single-dose container (0.25 mL) into affected ear twice daily for 7 days 6
• Ofloxacin otic solution: For patients 13 years and older, instill ten drops (0.5 mL) into affected ear once daily for seven days; for pediatric patients (6 months to 13 years), instill five drops (0.25 mL) once daily for seven days 5

Pain Management

• Assess pain severity and prescribe appropriate analgesics, with pain typically improving 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 2, 4

Special Considerations

• Systemic antibiotics should NOT be used as initial therapy for uncomplicated otitis externa 1, 2
• Reserve oral antibiotics for specific circumstances:
  • Extension of infection beyond the ear canal 1, 2
  • Patients with diabetes or immunocompromised status 1, 2
  • When topical therapy cannot reach the infected area or has failed 1, 2
• For diabetic or immunocompromised patients, monitor carefully for signs of necrotizing otitis externa 1, 2
• For suspected fungal otitis externa, use topical antifungals and debridement, avoiding antibacterial drops that may promote fungal overgrowth 1, 7

Patient Education

• Inform patients that symptoms typically improve within 48-72 hours 1, 2
• Instruct patients to complete the full course of therapy even if symptoms resolve early 1, 2
• Keep the ear dry during treatment 2, 8
• Adherence to therapy increases significantly when someone other than the patient applies the drops 3, 1

Common Pitfalls to Avoid

• Overuse of oral antibiotics for uncomplicated cases 1, 2
• Using ototoxic preparations when tympanic membrane integrity is compromised 1, 2
• Inadequate pain management 1, 2
• Failure to remove debris before administering drops 3, 2
• Missing fungal infections, especially in patients with diabetes 1, 2
• Poor administration technique leading to inadequate drug delivery 3, 1