What is the treatment for inner ear infections?

Treatment of Inner Ear Infections

Topical antimicrobials are the mainstay of treatment for inner ear infections, while systemic antibiotics should be reserved for specific cases with extension beyond the ear canal or in immunocompromised patients. 1

Types of Inner Ear Infections

• Inner ear infections (labyrinthitis) can be caused by viral, bacterial, or fungal pathogens, with bacterial infections most commonly caused by Pseudomonas aeruginosa (20-60%) and Staphylococcus aureus (10-70%) 1
• Symptoms typically include ear pain (often severe), itching, fullness, and sometimes hearing loss, with rapid onset generally within 48 hours 1
• Inner ear infections may also present with vertigo, tinnitus, and sensory hearing loss, distinguishing them from external and middle ear infections 2

First-Line Treatment

• Topical antimicrobial therapy is the primary treatment for inner ear infections, delivering antimicrobial concentrations 100-1000 times higher than systemic therapy 1
• Treatment should begin with cleaning the ear canal mechanically, rinsing with saline, and drying by suction to ensure effective drug delivery 3
• For bacterial infections, a combination broad-spectrum antibiotic/corticosteroid ear drop is most effective 3, 4
• Patients should expect improvement within 48-72 hours of initiating appropriate topical therapy 1

Proper Administration of Ear Drops

• Have the patient lie down with the affected ear up and fill the ear canal with enough drops to fill it completely 4
• Maintain this position for 3-5 minutes to allow adequate penetration of drops into the ear canal 4
• A gentle to-and-fro movement of the ear or tragal pumping (pressing on the small piece of cartilage in front of the ear) can help the drops reach their intended destination 4
• If drops do not easily run into the ear canal, the patient may need to have the ear canal cleaned by a clinician or have a wick placed to facilitate medication delivery 4

Special Considerations

• For patients with non-intact tympanic membranes (perforation or tympanostomy tubes), non-ototoxic preparations should be used 1
• Patients with diabetes, immunocompromised states, or history of radiotherapy require special attention as they are susceptible to otomycosis and necrotizing otitis externa 1
• Fungal infections require thorough cleaning of the ear canal followed by topical antifungal medication 3
• If symptoms persist beyond 48-72 hours, consider treatment failure, allergic contact dermatitis, or misdiagnosis 1

When to Use Systemic Antibiotics

• Systemic antimicrobials should not be prescribed as initial therapy for uncomplicated inner ear infections 4, 1
• Systemic antibiotics are indicated only when there is extension of infection outside the ear canal or in patients with specific host factors (diabetes, immunocompromised state) 4
• For severe infections that extend beyond the ear canal, conservative treatment with long-term antimicrobials is the mainstay, with surgery reserved for biopsy, microbial sampling, or removal of necrotic tissue 4

Prevention Strategies

• Remove obstructing cerumen regularly 1
• Use acidifying ear drops before and after swimming 1
• Dry the ear canal with a hair dryer after water exposure 1
• Use ear plugs while swimming 1
• Avoid unnecessary oral antibiotics, which add cost without improving outcomes for uncomplicated cases 1

When to Seek Specialist Care

• If symptoms persist beyond 7 days despite appropriate treatment 4
• If there is excessive wax build-up in the ear canal that cannot be safely removed 4
• If the patient experiences hearing loss, continued ear infections, or continued ear pain/discomfort 4
• If drainage from the ears occurs frequently or continues for more than 7 days 4
• For patients with complications such as facial palsy or vertigo, which may indicate labyrinthitis requiring urgent intervention 2