What is the treatment and management for an adult with an ear infection?

Treatment and Management of Ear Infections in Adults

For adults with ear infections, topical antibiotic drops (with or without corticosteroids) are the first-line treatment for otitis externa, while systemic antibiotics like amoxicillin-clavulanate are reserved for acute otitis media or complicated cases with extension beyond the ear canal. 1, 2

Distinguishing the Type of Ear Infection

The first critical step is determining whether you're dealing with otitis externa (outer ear canal infection) or acute otitis media (middle ear infection):

• Otitis externa is the most common ear infection in adults, affecting approximately 10% of people during their lifetime 1, 2
• Classic diagnostic sign: Tenderness when moving the tragus or pinna strongly suggests otitis externa 1, 3, 4
• Otitis externa symptoms: Ear pain (otalgia), itching, ear canal swelling and redness, discharge (otorrhea), often following swimming or ear canal trauma 1, 3
• Acute otitis media symptoms: Sudden onset of fever, ear pain, discharge, with a reddened/bulging tympanic membrane on examination 1, 5
• Acute otitis media is less common in adults than children but involves the same bacterial pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) 2, 5

Assessment of Modifying Factors (Critical Step)

Before initiating treatment, you must assess for factors that fundamentally change management: 1, 2

• Non-intact tympanic membrane or tympanostomy tubes (requires non-ototoxic preparations) 1, 2, 6
• Diabetes mellitus or immunocompromised state (higher risk for necrotizing otitis externa and fungal infections; may require systemic antibiotics) 1, 2, 6
• Prior radiotherapy (may require systemic antimicrobials) 2
• Recent antibiotic exposure (increases risk of resistant organisms or fungal superinfection) 1

First-Line Treatment for Uncomplicated Otitis Externa

Topical antibiotic therapy is superior to systemic antibiotics because it delivers 100-1000 times higher antibiotic concentrations directly to the infection site: 1, 2, 6

• Recommended topical agents: Combination antibiotic-corticosteroid drops (such as neomycin/polymyxin B/hydrocortisone when tympanic membrane is intact) 3, 4
• Alternative topical options: Acetic acid 2%, aminoglycosides, polymyxin B, or quinolones with or without corticosteroids 3, 4
• No single topical preparation is clinically superior to another; choice depends on tympanic membrane status, cost, and patient adherence 3, 4
• Corticosteroid-containing drops may provide faster pain relief 2

Proper Administration Technique

Correct drop administration is essential for treatment success: 6

• Have the patient lie down with the affected ear facing up 6
• Fill the ear canal completely with drops 6
• Maintain this position for 3-5 minutes to allow adequate penetration 6
• Gentle tragal pumping or to-and-fro ear movement helps drops reach their destination 6

Pain Management (Essential Component)

Pain relief must be addressed, especially in the first 24 hours: 1, 2

• Systemic analgesics (acetaminophen or ibuprofen) should be offered to all patients based on pain severity 1, 2
• Topical analgesics may reduce ear pain within 10-30 minutes, though evidence quality is limited 2

When Systemic Antibiotics Are Indicated

Do NOT prescribe oral antibiotics for uncomplicated otitis externa—this is a strong recommendation to prevent antibiotic resistance: 1, 2

Systemic antibiotics ARE indicated for: 1, 2

• Acute otitis media (middle ear infection) 2, 5
• Extension of infection beyond the ear canal (cellulitis of surrounding tissues) 1, 2, 4
• High-risk patients: Diabetes, immunocompromised state, or conditions preventing topical therapy 1, 2, 4

Systemic Antibiotic Regimens for Acute Otitis Media

For confirmed acute otitis media in adults, amoxicillin-clavulanate is first-line: 2, 7

• Standard dose: 1.75 g amoxicillin/250 mg clavulanate per day for mild-moderate disease 2
• High-dose: 4 g amoxicillin/250 mg clavulanate per day for recent antibiotic exposure or moderate disease 2
• Predicted clinical efficacy: 90-92% in adults 2
• For penicillin allergy: Respiratory fluoroquinolones (levofloxacin, moxifloxacin) provide 90-92% efficacy 2
• Azithromycin is less effective with 20-25% bacteriologic failure rates 2

Expected Timeline and Treatment Failure

Symptoms should improve within 48-72 hours of initiating appropriate therapy: 2, 6, 4

If no improvement by 48-72 hours, you must: 2

• Reassess to confirm the diagnosis and exclude other conditions 2
• Consider treatment failure, allergic contact dermatitis (especially to neomycin), or misdiagnosis 1, 6
• For confirmed treatment failure, switch to a different antibiotic class rather than increasing dose 2
• Do not continue the same antibiotic beyond 72 hours without improvement 2

Critical Pitfalls to Avoid

Common errors that worsen outcomes: 1, 2, 6

• Prescribing oral antibiotics for uncomplicated otitis externa increases antibiotic resistance without clinical benefit 1, 2
• Missing necrotizing otitis externa in diabetic or immunocompromised patients—this is a life-threatening condition requiring aggressive treatment 1, 2, 6
• Failing to consider fungal infection when standard bacterial treatment fails, especially after antibiotic use 1, 2, 6
• Using ototoxic drops (aminoglycosides like neomycin) when tympanic membrane is not intact 2, 6
• Inadequate pain management, particularly in the first 24 hours 1, 2

When to Refer to Specialist

Refer to otolaryngology if: 6

• Symptoms persist beyond 7 days despite appropriate treatment 6
• Hearing loss develops or persists 6
• Excessive cerumen cannot be safely removed in primary care 6
• Recurrent infections occur 6
• Suspected necrotizing otitis externa or skull base involvement 1

Prevention Strategies

To reduce recurrence risk: 1, 6

• Remove obstructing cerumen regularly 1, 6
• Use acidifying ear drops before and after swimming 1, 6
• Dry ear canal with hair dryer after water exposure 1, 6
• Use ear plugs while swimming 1, 6
• Avoid ear canal trauma from cotton swabs or other objects 4