Treatment of Otitis Externa
Topical antimicrobial therapy is the definitive first-line treatment for uncomplicated acute otitis externa—oral antibiotics should NOT be used initially. 1, 2
Initial Management Steps
Perform aural toilet first to remove debris and enhance medication delivery before administering any topical therapy. 1, 2 This can be accomplished through:
Place a wick in the ear canal if edema prevents drop entry or if most of the tympanic membrane cannot be visualized, ensuring effective delivery of topical antimicrobial preparations. 1
Topical Antimicrobial Selection
For Intact Tympanic Membrane
Prescribe topical preparations effective against Pseudomonas aeruginosa and Staphylococcus aureus (the causative pathogens in 98% of cases), including: 1, 3
Adding a topical steroid to antimicrobial drops may help reduce inflammation and hasten pain relief. 1
For Non-Intact Tympanic Membrane
Use ONLY non-ototoxic quinolone preparations if there is tympanic membrane perforation or tympanostomy tubes present: 1, 2, 3
- Ciprofloxacin 0.2% otic solution: 0.25 mL (contents of one single-dose container) instilled into affected ear twice daily for 7 days 4
- Ofloxacin 0.3% otic solution: 5 drops (pediatric 6 months-13 years) or 10 drops (≥13 years) once daily for 7 days 5, 6
Never use aminoglycosides or polymyxin B preparations when tympanic membrane integrity is compromised due to ototoxicity risk. 1, 2
Pain Management
Assess pain severity and prescribe appropriate analgesics, as pain from otitis externa can be intense due to the highly sensitive periosteum of the underlying bone. 1, 3
- For mild to moderate pain: Acetaminophen or NSAIDs 3
- For severe pain: Consider short-term opioid-containing analgesics for the initial 48-72 hours 1, 3
Pain typically improves within 48-72 hours of starting appropriate treatment. 1, 2
When Systemic Antibiotics ARE Indicated
Reserve oral antibiotics for specific circumstances only: 1, 2, 3
- Extension of infection beyond the ear canal 1, 2
- Patients with diabetes mellitus or immunocompromised status 1, 2, 3
- When topical therapy cannot reach the infected area 1, 2
- Treatment failure with topical therapy 1, 2
When systemic antibiotics are indicated, use fluoroquinolones (e.g., ciprofloxacin) for coverage against P. aeruginosa and S. aureus. 2
Special Populations Requiring Modified Management
Diabetic or Immunocompromised Patients
Monitor carefully for signs of necrotizing otitis externa and consider adding systemic antibiotics. 1, 2 These patients are more susceptible to:
If fungal infection is suspected, treat with topical antifungals and debridement, avoiding antibacterial drops that may promote fungal overgrowth. 2
Patient Education and Administration Technique
Instruct patients on proper eardrop administration: 1
- Warm the solution by holding the bottle in hand for 1-2 minutes 4, 5
- Lie down with affected ear upward 1, 4
- Fill the ear canal with drops 1
- Remain in position for 3-5 minutes 1, 4
- Apply gentle to-and-fro movement of the ear to help drops penetrate 1
Keep the ear dry during treatment. 1, 3
Complete the full course of therapy even if symptoms resolve early. 1, 2
Expected Clinical Course and Treatment Failure
Symptoms typically improve within 48-72 hours. 1, 2 If no improvement is seen at this timepoint, reassess for: 2
- Inadequate drug delivery due to canal obstruction 2
- Poor adherence to therapy 2
- Incorrect diagnosis 2
- Fungal co-infection 2
- Contact dermatitis from topical agents 2
Common Pitfalls to Avoid
Do NOT:
- Overuse oral antibiotics for uncomplicated cases (approximately 20-40% of patients inappropriately receive oral antibiotics) 1, 2
- Use ototoxic preparations when tympanic membrane integrity is compromised 1, 2
- Provide inadequate pain management 1
- Fail to remove debris before administering drops 1
- Miss fungal infections, especially in patients with diabetes 1, 2
- Use ear candles, which have no proven efficacy and can cause harm 1