What is the treatment for otitis externa and otitis media in adults?

Treatment of Otitis Externa and Otitis Media in Adults

The mainstay treatment for uncomplicated otitis externa is topical antimicrobial therapy effective against common pathogens such as Pseudomonas aeruginosa and Staphylococcus aureus, while most cases of acute otitis media resolve spontaneously with fewer patients requiring antibiotic treatment. 1, 2, 3

Otitis Externa Treatment Algorithm

Initial Assessment and Management

• Assess for modifying factors that might alter management (non-intact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state) 1
• Evaluate pain severity and prescribe appropriate analgesics based on pain level 1, 2
• Perform aural toilet (cleaning the ear canal) before administering drops to ensure medication reaches infected tissues 2, 4

Topical Antimicrobial Selection

• For intact tympanic membrane: Use any FDA-approved topical antimicrobial preparation (all are highly effective with no consistent advantage for any specific drug) 2, 3
• For non-intact tympanic membrane or tympanostomy tubes: Use non-ototoxic preparations such as quinolones (ofloxacin, ciprofloxacin) 1, 5, 6
• Recommended options:
  • Ofloxacin 0.3% otic solution (indicated for otitis externa due to E. coli, P. aeruginosa, and S. aureus) 5
  • Ciprofloxacin otic suspension (indicated for acute otitis externa due to S. aureus and P. aeruginosa) 6

Administration and Duration

• Instill drops properly after cleaning the ear canal 2, 4
• Once-daily regimen of ofloxacin otic solution for 7 days has shown 91% cure rates in clinical trials 7
• Expect symptom improvement within 48-72 hours of starting appropriate treatment 1, 3

Special Considerations

• For diabetic or immunocompromised patients: Monitor carefully for signs of necrotizing otitis externa and consider adding systemic antibiotics 2, 3
• For fungal infections: Thorough cleaning and specific topical antifungal medication are essential 4, 8

Systemic Antibiotics - When to Use

• Do not prescribe systemic antimicrobials as initial therapy for uncomplicated otitis externa 1
• Use systemic antibiotics only when:
  • Infection extends beyond the ear canal 1, 3
  • Patient has diabetes or is immunocompromised 3, 8
  • Topical therapy cannot reach infected area or has failed 3
  • Consider fluoroquinolones (e.g., ciprofloxacin) for systemic coverage against P. aeruginosa and S. aureus 3, 9

Otitis Media Treatment

• Most cases of acute otitis media resolve spontaneously 1, 2
• For acute otitis media with tympanostomy tubes: Topical antibiotic therapy is superior to systemic antibiotics 2, 3
• For chronic suppurative otitis media with perforated tympanic membranes: Use non-ototoxic topical preparations such as ofloxacin otic solution 5

Follow-up and Treatment Failure

• Reassess patients who fail to respond to initial therapy within 48-72 hours 1
• If treatment fails, consider:
  • Inadequate drug delivery due to canal obstruction 1
  • Poor adherence to therapy 1
  • Incorrect diagnosis 1
  • Fungal infection 1, 4
  • Bacterial resistance (increasing resistance to neomycin and polymyxin B has been reported) 10
  • Contact dermatitis from topical agents 3

Common Pitfalls to Avoid

• Overuse of oral antibiotics for uncomplicated otitis externa 2, 3
• Using ototoxic preparations when tympanic membrane integrity is compromised 1, 2
• Inadequate pain management 2, 3
• Failure to remove debris before administering drops 2, 4
• Missing fungal infections, especially in patients with diabetes 3, 4