What is the 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 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 ensure effective delivery of topical antimicrobials 3, 2
• Prescribe topical antimicrobial preparations effective against common pathogens, such as those containing aminoglycosides, polymyxin B, or quinolones 1, 2
• Adding a topical steroid to antimicrobial drops helps reduce inflammation and hasten pain relief 2, 4

Medication Selection

• For intact tympanic membrane, ofloxacin 0.3% otic solution is an effective option 5, 6
• For non-intact tympanic membrane (perforation or tympanostomy tubes), use only non-ototoxic preparations such as quinolones (ciprofloxacin or ofloxacin) to avoid potential ototoxicity 2, 5
• Neomycin/polymyxin B/hydrocortisone preparations are reasonable first-line therapy when the tympanic membrane is intact, though increasing resistance has been reported 4, 7
• Topical antimicrobial preparations should be continued for 7-10 days, even if symptoms resolve earlier 2, 6

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

Special Considerations

• For diabetic or immunocompromised patients, avoid irrigation and use atraumatic cleaning with aural suctioning 3, 5
• Monitor diabetic or immunocompromised patients carefully for signs of necrotizing otitis externa 2, 5
• For suspected fungal infection, use topical antifungal therapy and debridement, avoiding antibacterial drops that may promote fungal overgrowth 1, 5

When to Use Systemic Antibiotics

• 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, 5
  • Patients with diabetes or immunocompromised status 2, 5
  • When topical therapy cannot reach the infected area or has failed 1, 2

Patient Education

• Instruct patients on proper administration of eardrops: lying down with the affected ear up, filling the ear canal with drops, remaining in position for 3-5 minutes, and applying gentle to-and-fro movement of the ear to help drops penetrate 3, 2
• Adherence to therapy increases significantly when someone other than the patient applies the drops 3
• Keep the ear dry during treatment 2
• Inform patients that symptoms typically improve within 48-72 hours and to complete the full course of therapy 2, 5

Common Pitfalls to Avoid

• Overuse of oral antibiotics for uncomplicated cases 1, 2
• Using ototoxic preparations when tympanic membrane integrity is compromised 2, 5
• Inadequate pain management 2, 5
• Failure to remove debris before administering drops 3, 2
• Missing fungal infections, especially in patients with diabetes 1, 5
• Prolonged use of antibiotic preparations may result in overgrowth of nonsusceptible organisms, including fungi 8, 9