What is the treatment for otitis externa?

Treatment of Otitis Externa

The first-line treatment for otitis externa is topical antimicrobial therapy, which should be combined with appropriate aural toilet to remove debris and ensure medication delivery to the infected area. 1, 2

Initial Management

• Perform aural toilet to remove inflammatory debris, obstructing cerumen, or foreign objects before administering topical medication to ensure effective drug delivery 3, 1
• Methods for aural toilet include gentle lavage using body-temperature water, saline solution, hydrogen peroxide, or physically removing debris with suction or dry mopping with cotton-tipped applicators 3
• For diabetic or immunocompromised patients, avoid ear canal irrigation as it may contribute to malignant otitis externa; instead, use atraumatic cleaning with aural suctioning under microscopic guidance 3, 1
• Prescribe topical antimicrobial preparations effective against common pathogens such as Pseudomonas aeruginosa and Staphylococcus aureus 1, 2

Medication Selection

• For intact tympanic membrane, use topical preparations containing aminoglycosides, polymyxin B, quinolones (ciprofloxacin or ofloxacin), or low-pH antiseptics 1, 2
• For non-intact tympanic membrane (perforation or tympanostomy tubes), use only non-ototoxic preparations such as quinolone drops (ciprofloxacin or ofloxacin) 1, 2
• Ciprofloxacin 0.2% otic solution is administered as 0.25 mL (5 drops for children, 10 drops for adults) instilled into the affected ear twice daily for 7 days 4
• Ofloxacin otic solution is administered as 5 drops for pediatric patients or 10 drops for patients 13 years and older, once daily for seven days 5
• Adding a topical steroid to antimicrobial drops may help reduce inflammation and hasten pain relief 2, 6

Ear Wick Placement

• Place a wick in the ear canal if edema prevents drop entry or if most of the tympanic membrane cannot be visualized 3
• Use compressed cellulose wicks (preferred) or ribbon gauze, as they expand when exposed to moisture, facilitating drug delivery and reducing ear canal edema 3, 1
• Prime the wick with six drops before starting the treatment regimen to ensure full absorption of the medication 7
• The wick may fall out spontaneously as edema subsides (usually within 24 hours to a few days), or may be removed by the patient or clinician at a follow-up visit 3, 1

Proper Administration of Ear Drops

• Have the patient lie with the affected ear upward and instill enough drops to fill the ear canal 3
• Maintain this position for 3-5 minutes to facilitate penetration of drops into the ear canal 3
• Apply gentle to-and-fro movement of the pinna or press with an in/out movement on the tragus to help drops penetrate 3
• After placing drops, the canal should be left open to dry and avoid trapping moisture 3, 1
• Having someone else administer the drops significantly improves adherence to therapy, as only 40% of patients who self-medicate do so appropriately during the first 3 days 3

Pain Management

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

Systemic Antibiotics

• Systemic antibiotics should NOT be used as initial therapy for uncomplicated otitis externa 2, 8
• Reserve oral antibiotics for specific circumstances, such as extension of infection beyond the ear canal, patients with diabetes or immunocompromised status, or when topical therapy cannot reach the infected area or has failed 1, 2

Common Pitfalls to Avoid

• Overuse of oral antibiotics for uncomplicated cases, which increases treatment costs and the likelihood of side effects 2, 8
• Using ototoxic preparations when tympanic membrane integrity is compromised 1, 2
• Inadequate pain management 1, 2
• Failure to remove debris before administering drops, which can prevent effective drug delivery 3, 9
• Missing fungal infections, especially in patients with diabetes 1, 2
• Failure to prime ear wicks with sufficient drops (six drops needed) before starting treatment regimen 7

Special Considerations

• For diabetic or immunocompromised patients, monitor carefully for signs of necrotizing otitis externa 1, 2
• For suspected fungal infection, use topical antifungal therapy and thorough debridement 1, 9
• Continue treatment for the full prescribed duration (typically 7 days) even if symptoms improve sooner, to prevent relapse 1, 2