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), not systemic antibiotics, as it delivers medication concentrations 100-1000 times higher than systemic therapy and effectively targets common pathogens like Pseudomonas aeruginosa and Staphylococcus aureus. 1, 2, 3

Initial Management Algorithm

• Perform aural toilet to remove debris and ensure medication delivery before administering drops, using gentle suction, dry mopping, or irrigation 1, 2, 3
• Prescribe topical antimicrobial preparation effective against common pathogens (Pseudomonas aeruginosa and Staphylococcus aureus) 1, 3
• Assess pain and provide appropriate analgesics based on severity 1, 2, 3
• Place a wick in the ear canal if edema prevents drop entry or if most of the tympanic membrane cannot be visualized 3

Medication Selection

• For intact tympanic membrane: Aminoglycoside/polymyxin B combinations with steroid (e.g., neomycin/polymyxin B/hydrocortisone) are effective first-line options 3, 4
• For non-intact tympanic membrane (perforation or tympanostomy tubes): Use only non-ototoxic preparations such as quinolones (ciprofloxacin 0.2% or ofloxacin 0.3%) 1, 2, 3, 5
• Ofloxacin otic solution once daily for 7 days has been shown to be effective and may improve adherence compared to more frequent dosing regimens 6, 7
• Adding a topical steroid to antimicrobial drops helps reduce inflammation and hasten pain relief 3, 4

Pain Management

• Pain typically improves within 48-72 hours of starting appropriate treatment 1, 2, 3
• For mild to moderate pain: Use acetaminophen or NSAIDs 3
• For severe pain: Consider short-term opioid-containing analgesics for the initial 48-72 hour period 3

Special Considerations

• Systemic antibiotics should NOT be used as initial therapy for uncomplicated otitis externa 1, 2, 3
• Reserve oral antibiotics for specific circumstances:
  • Extension of infection beyond the ear canal 1, 3
  • Patients with diabetes or immunocompromised status 1, 3
  • When topical therapy cannot reach the infected area or has failed 1, 3
• For diabetic patients: Monitor closely for necrotizing otitis externa, which can be life-threatening 1, 8
• For suspected fungal otitis externa: Use topical antifungals and debridement, avoiding antibacterial drops that may promote fungal overgrowth 1

Patient Education

• Instruct patients on proper administration of eardrops:
  • Lie down with the affected ear up 3
  • Fill the ear canal with drops 3
  • Remain in position for 3-5 minutes 3
  • Apply gentle to-and-fro movement of the ear to help drops penetrate 3
• Inform patients that symptoms typically improve within 48-72 hours 1, 3
• Complete the full course of therapy (typically 7 days) even if symptoms resolve early 2, 3
• Keep the ear dry during treatment 3
• Return for reassessment if symptoms don't improve within 48-72 hours 1, 3

Common Pitfalls to Avoid

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

Follow-up and Treatment Failure

• Reassess within 48-72 hours if no improvement is seen 2, 3
• Consider treatment failure if symptoms persist beyond 7 days 2
• Reasons for treatment failure may include:
  • Inadequate drug delivery due to canal obstruction 1, 3
  • Poor adherence to therapy 1, 3
  • Incorrect diagnosis 1, 3
  • Fungal infection 1, 3
  • Contact dermatitis from topical agents 1, 3