Treatment of Otitis Externa
The mainstay of treatment for uncomplicated acute otitis externa is topical antimicrobial therapy effective against common pathogens such as Pseudomonas aeruginosa and Staphylococcus aureus. 1
First-Line Treatment
- Topical antimicrobial therapy is recommended as the primary treatment for uncomplicated acute otitis externa 1
- Aural toilet (gentle suction, dry mopping, irrigation, or removal of debris) should be performed before administering drops to ensure medication reaches infected tissues 1
- Topical quinolone antimicrobials such as ciprofloxacin 0.2% or ofloxacin 0.3% are effective first-line options 2, 3
- Ciprofloxacin otic solution 0.2% should be instilled twice daily for 7 days 2
- Ofloxacin otic solution 0.3% can be administered once daily for 7 days (5 drops for children aged 6 months to <13 years, 10 drops for adults) 3, 4
- Warm the solution by holding the bottle in hand for 1-2 minutes before administration to prevent dizziness 2, 3
Pain Management
- Pain assessment and management is essential in acute otitis externa 1
- Appropriate analgesics should be prescribed based on pain severity 1
- Pain typically improves within 48-72 hours of starting treatment 1
- Options include acetaminophen or nonsteroidal anti-inflammatory drugs for mild to moderate pain 5
- For severe pain, consider short-term opioid-containing analgesics for the initial 48-72 hours 5
Special Considerations
Fungal Otitis Externa
- Suspect fungal infection if patient fails to respond to initial antibacterial therapy or has risk factors such as diabetes or immunocompromised status 5, 6
- Treatment includes thorough aural toilet followed by topical antifungals or boric acid solutions 5, 6
- Avoid antibacterial drops for fungal infections as they may promote fungal overgrowth 5, 6
- Consider obtaining a fungal culture to identify the specific pathogen 5
Perforated Tympanic Membrane
- Avoid ototoxic preparations in patients with perforated tympanic membrane or tympanostomy tubes 1
- Use non-ototoxic preparations such as quinolones (ciprofloxacin, ofloxacin) 1, 7
When to Use Systemic Antibiotics
- Oral antibiotics should NOT be used as initial therapy for uncomplicated otitis externa 1
- Reserve systemic antibiotics for specific circumstances: 1
- Extension of infection beyond the ear canal
- Patients with diabetes or immunocompromised status
- When topical therapy cannot reach the infected area or has failed
- When needed, choose antibiotics with coverage against Pseudomonas aeruginosa and Staphylococcus aureus 1
Follow-up and Treatment Failure
- Patients should expect improvement within 48-72 hours of initiating appropriate therapy 1, 5
- Complete the full course of therapy even if symptoms resolve early 1, 5
- Reassess patients within 48-72 hours if no improvement is seen 1
- Reasons for treatment failure may include: 1
- Inadequate drug delivery due to canal obstruction
- Poor adherence to therapy
- Incorrect diagnosis
- Fungal infection
- Contact dermatitis from topical agents
Common Pitfalls to Avoid
- Overuse of oral antibiotics for uncomplicated cases 1
- Using ototoxic preparations when tympanic membrane integrity is compromised 1
- Inadequate pain management 1
- Failure to remove debris before administering drops 1
- Missing fungal infections, especially in patients with diabetes or those who fail to respond to antibacterial therapy 1, 5
- Patients tend to overadminister ear drops when pain is greatest and underadminister as symptoms resolve 1