What is the recommended treatment for otitis externa in a 23-month-old child with ear tubes?

Treatment of Otitis Externa in a 23-Month-Old Child with Ear Tubes

For otitis externa in a 23-month-old child with ear tubes, the recommended treatment is antibiotic ear drops alone, specifically ofloxacin or ciprofloxacin-dexamethasone, administered twice daily for 10 days. 1

First-Line Treatment

• Topical antibiotic ear drops are the treatment of choice for otitis externa in children with tympanostomy tubes 1
• For a 23-month-old child, the FDA-approved dosage is five drops (0.25 mL, 0.75 mg ofloxacin) instilled into the affected ear twice daily for ten days 2
• Topical therapy has demonstrated superior outcomes compared to systemic antibiotics, with clinical cure rates of 77-96% versus 30-67% for oral antibiotics 1

Administration Technique

• Warm the solution by holding the bottle in hand for 1-2 minutes to prevent dizziness 2
• Position the child with the affected ear upward 2
• After instilling drops, pump the tragus (flap of skin in front of ear canal) 4 times to facilitate penetration into the middle ear 1, 2
• Maintain this position for five minutes 2
• Clean any drainage or debris from the ear canal before administering drops using:
  • Cotton-tipped swab dipped in hydrogen peroxide or warm water 1
  • Cotton ball to absorb drainage 1
  • Gentle suction with an infant nasal aspirator 1
  • Tissue spears to assist in cleaning 1

Why Topical Treatment is Superior

• Provides significantly higher drug concentration at the infection site (up to 1000 times higher than systemic therapy) 1
• Better coverage of likely pathogens, especially Pseudomonas aeruginosa and Staphylococcus aureus 1
• Avoids adverse events associated with systemic antibiotics including dermatitis, allergic reactions, gastrointestinal upset, oral thrush, and increased antibiotic resistance 1

Water Precautions During Treatment

• Prevent water entry into the ear canal during bathing or hair washing 1
• Use a piece of cotton saturated with Vaseline to cover the ear canal opening 1
• No swimming until the drainage stops 1

When to Consider Systemic Antibiotics

Oral antibiotics should be reserved for specific situations:

• When the infection has spread beyond the ear canal 1
• If the child is very ill 1
• If the child has another reason to be on an antibiotic 1
• If the infection does not improve after using ear drops 1
• Signs of severe infection (high fever, severe otalgia, toxic appearance) 1

Important Cautions

• Use only topical drops approved for use with tympanostomy tubes (ofloxacin or ciprofloxacin-dexamethasone) to avoid potential ototoxicity from aminoglycoside-containing eardrops 1
• Limit topical therapy to a single course of no more than 10 days to avoid fungal external otitis 1
• If drainage continues for more than 7 days or occurs frequently, consult an otolaryngologist 1
• About 4-8% of children treated with topical quinolone otic drops may require oral antibiotic rescue therapy for persistent symptoms 1

Follow-up Recommendations

• If symptoms persist beyond 7 days despite appropriate treatment, reassessment is needed 1
• Consider culturing persistent drainage to detect resistant pathogens such as MRSA or fungi 1
• Routine follow-up with a physician every 4-6 months is important to ensure tubes are in place and functioning properly 1