What is the treatment for otitis externa?

Treatment of Otitis Externa

Topical antimicrobial therapy is the first-line treatment for uncomplicated acute otitis externa (AOE), 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 (gentle suction, dry mopping, or irrigation) to remove debris before administering drops to ensure medication reaches infected tissues 3, 2
• Place a wick in the ear canal if edema prevents drop entry or if most of the tympanic membrane cannot be visualized 2
• Prescribe topical antimicrobial preparations containing antibiotics (aminoglycosides, polymyxin B, quinolones), steroids, or low-pH antiseptics 1, 2
• Meta-analyses show no significant differences in clinical outcomes based on class of drug (antibiotic vs antiseptic), quinolone versus non-quinolone preparations, or monotherapy versus combination drugs 1
• Acetic acid preparations are FDA-approved for treating superficial infections of the external auditory canal 4

Medication Selection Considerations

• For patients with non-intact tympanic membranes (perforation or tympanostomy tubes), use only non-ototoxic preparations such as quinolones (ciprofloxacin or ofloxacin) 1, 3, 2
• Adding a topical steroid to antimicrobial drops may help reduce inflammation and hasten pain relief 2, 5
• Consider increasing resistance patterns when selecting therapy; some studies have shown declining susceptibility to neomycin and polymyxin B while ofloxacin susceptibility has remained stable 6
• Neomycin/polymyxin B/hydrocortisone preparations are a reasonable first-line therapy when the tympanic membrane is intact 5

Pain Management

• Assess pain severity and prescribe appropriate analgesics based on severity 1, 3, 2
• Pain typically improves within 48-72 hours of starting appropriate treatment 1, 3, 2
• For severe pain, consider short-term opioid-containing analgesics for the initial 48-72 hour period 2

Special Considerations

• Systemic antibiotics should NOT be used as initial therapy for uncomplicated otitis externa 1, 3, 2
• Reserve oral antibiotics for specific circumstances:
  • Extension of infection beyond the ear canal 1, 3, 2
  • Patients with diabetes or immunocompromised status 1, 3, 2
  • When topical therapy cannot reach the infected area or has failed 1, 3, 2
• For diabetic or immunocompromised patients, monitor carefully for signs of necrotizing otitis externa, which can be life-threatening 3, 7
• For suspected fungal otitis externa, use topical antifungals and debridement, avoiding antibacterial drops that may promote fungal overgrowth 3

Patient Education

• Instruct patients on proper administration of eardrops:
  • Lying down with the affected ear up 2
  • Filling the ear canal with drops 2
  • Remaining in position for 3-5 minutes 2
  • Applying gentle to-and-fro movement of the ear to help drops penetrate 2
• Inform patients that symptoms typically improve within 48-72 hours 1, 3, 2
• Complete the full course of therapy even if symptoms resolve early 3, 2
• Keep the ear dry during treatment 2

Treatment Expectations and Follow-up

• Reassess patients within 48-72 hours if no improvement is seen 1, 3
• Reasons for treatment failure may include:
  • Inadequate drug delivery due to canal obstruction 3
  • Poor adherence to therapy 3
  • Incorrect diagnosis 3
  • Fungal infection 3
  • Contact dermatitis from topical agents 3

Common Pitfalls to Avoid

• Overuse of oral antibiotics for uncomplicated cases 1, 3, 2
• Using ototoxic preparations when tympanic membrane integrity is compromised 1, 3, 2
• Inadequate pain management 1, 3, 2
• Failure to remove debris before administering drops 1, 3, 2
• Missing fungal infections, especially in patients with diabetes or those who fail to respond to antibacterial therapy 1, 3, 2
• Using ear candles, which have no proven efficacy and can cause harm 2