What is the treatment for ear discharge?

Treatment of Ear Discharge

Topical antibiotic ear drops (ofloxacin or ciprofloxacin-dexamethasone) are the first-line treatment for ear discharge, administered twice daily for up to 10 days, with superior efficacy and safety compared to systemic antibiotics. 1, 2

Clinical Context and Pathophysiology

Ear discharge most commonly results from acute otitis media with tympanic membrane perforation or from ventilation tube-associated infections. 1 The predominant bacterial pathogens include Pseudomonas aeruginosa, Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. 1, 2 In children with ventilation tubes, discharge occurs in 26-75% of cases and significantly impacts quality of life. 1

First-Line Treatment: Topical Antibiotics

Quinolone ear drops (with or without corticosteroids) should be prescribed as initial therapy for uncomplicated ear discharge. 1, 2

Specific Regimens

• Ofloxacin ear drops or ciprofloxacin-dexamethasone combination drops twice daily for up to 10 days 1, 2
• Clinical cure rates with topical therapy: 77-96% versus systemic antibiotics: 30-67% 2
• Combination antibiotic-corticosteroid drops are superior to antibiotics alone 1

Why Topical Therapy is Superior

• Delivers higher drug concentrations directly at the infection site 2
• Better coverage of Pseudomonas aeruginosa, the most common pathogen in tube-associated discharge 1, 2
• Avoids systemic antibiotic adverse effects (GI upset, allergic reactions, oral thrush) 2
• Reduces antibiotic resistance development 2
• Quinolone drops have not demonstrated ototoxicity despite non-intact tympanic membrane 1

Critical Administration Technique

• Clean the ear canal first: Remove debris/discharge using cotton-tipped swab with hydrogen peroxide or warm water, or gentle suction with infant nasal aspirator 1, 2
• After instilling drops: "Pump" the tragus (flap of skin in front of ear canal) several times to facilitate drop entry into the middle ear 1, 2
• Prevent water entry: Use cotton saturated with Vaseline during bathing/hair washing; avoid swimming until discharge resolves 1, 2

When Systemic Antibiotics Are Indicated

Oral antibiotics should be reserved for specific situations: 2

• Cellulitis of the pinna or adjacent skin
• Concurrent bacterial infection at another site
• Signs of severe systemic infection (high fever, toxicity)
• Persistent or worsening discharge despite 7-10 days of topical therapy
• Patient too ill to use topical therapy alone

Important Caveats and Pitfalls

Duration Limits

Limit topical antibiotic therapy to a single 10-day course maximum to prevent fungal (yeast) infections of the ear canal. 1, 2

Avoid Ototoxic Agents

Never prescribe aminoglycoside-containing ear drops (e.g., neomycin, gentamicin) for patients with non-intact tympanic membranes or ventilation tubes due to ototoxicity risk. 1, 2 Only quinolone drops are safe in this setting.

Consider MRSA

In recurrent or treatment-resistant cases, suspect methicillin-resistant Staphylococcus aureus (MRSA) and consider culture-directed therapy. 2

Exclude Malignancy

In adults with persistent ear discharge despite adequate treatment, exclude malignant tumors (squamous cell carcinoma, basal cell carcinoma) by submitting all removed material for histological examination. 3, 4 Persistent discharge unresponsive to standard therapy warrants otolaryngology referral.

Follow-Up and Escalation

• If discharge persists beyond 7 days despite appropriate topical therapy, refer to otolaryngology 2
• For patients with ventilation tubes, routine follow-up every 4-6 months is essential to ensure proper tube function 1, 2, 5
• Children with acute otitis media presenting with ear discharge from spontaneous tympanic membrane perforation have poorer prognosis and require early treatment 6

Special Considerations for Acute Otitis Media Without Tubes

For acute otitis media with spontaneous perforation (no ventilation tubes), the same topical quinolone approach applies as first-line therapy. 1 However, if the tympanic membrane is intact without visible discharge, standard acute otitis media treatment with oral antibiotics (amoxicillin or amoxicillin-clavulanate) is appropriate. 1, 7