What is the recommended treatment for otitis externa?

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, 3

Essential Pre-Treatment Step

Before administering any ear drops, perform aural toilet to remove debris, cerumen, and inflammatory material from the ear canal. This ensures medication reaches infected tissues. 1, 2, 3 Methods include:

• Gentle suction under microscopic guidance (preferred in diabetic/immunocompromised patients) 1
• Dry mopping 1, 2
• Irrigation with body-temperature water, saline, or hydrogen peroxide 1, 2
• Avoid aggressive irrigation in diabetic or immunocompromised patients—this can trigger necrotizing otitis externa 1

If severe canal edema prevents drop entry or the tympanic membrane cannot be visualized, place a wick to facilitate medication delivery. 2, 3

First-Line Topical Treatment Selection

When Tympanic Membrane is INTACT or Status is CERTAIN:

Any FDA-approved topical preparation is acceptable, with 65-90% clinical cure rates within 7-10 days regardless of specific agent. 1 Options include:

• Ofloxacin 0.3%: Once daily dosing (5 drops for ages 6 months-13 years; 10 drops for ≥13 years) for 7 days 4, 5
• Neomycin/polymyxin B/hydrocortisone: Effective but carries 5-15% risk of contact dermatitis from neomycin 1
• Acetic acid 2%: Effective at week 1 but less effective than antibiotic/steroid if treatment extends beyond 7 days 1, 6

When Tympanic Membrane is PERFORATED, Status is UNCERTAIN, or Tympanostomy Tubes Present:

Use ONLY non-ototoxic fluoroquinolone preparations—never use aminoglycoside-containing drops due to ototoxicity risk. 1, 2, 3

• Ofloxacin 0.3%: 5-10 drops once daily for 7 days (age-dependent dosing) 1, 4
• Ciprofloxacin 0.2%: 0.25 mL (one single-dose container) twice daily for 7 days 7

The addition of topical steroids (hydrocortisone or fluocinolone) hastens pain relief and reduces inflammation. 1, 2 However, hydrocortisone causes contact sensitivity in 13-30% of patients with chronic otitis externa. 1

Proper Drop Administration Technique

Only 40% of patients self-administer drops correctly—having someone else apply drops significantly improves adherence. 1 Instruct patients:

• Warm bottle in hands for 1-2 minutes to prevent dizziness 1, 4, 7
• Lie with affected ear upward 1, 4, 7
• Fill ear canal completely with drops 1
• Maintain position for 3-5 minutes (ofloxacin) or at least 1 minute (ciprofloxacin) 4, 7
• Apply gentle to-and-fro movement of pinna or tragal pumping to eliminate trapped air 1

Pain Management

Pain assessment and appropriate analgesics are essential—pain typically improves within 48-72 hours of starting treatment. 1, 2, 3

• Mild-to-moderate pain: Acetaminophen or NSAIDs 1, 3
• Severe pain: Consider short-term opioid-containing analgesics for initial 48-72 hours 2, 3
• Avoid topical anesthetic drops (benzocaine): Not FDA-approved for active infections, can mask disease progression, and contraindicated with tympanostomy tubes or uncertain tympanic membrane integrity 1

Treatment Duration and Expected Course

• Minimum 7-day course even if symptoms resolve earlier 1, 5
• Pain improves within 48-72 hours 1, 2, 3
• Clinical resolution occurs in 65-90% of patients within 7-10 days 1, 5
• If symptoms persist beyond 7 days, continue drops until resolution for maximum of 7 additional days (total 14 days maximum) 1

When to Use Systemic Antibiotics

Oral antibiotics should NOT be used as initial therapy for uncomplicated otitis externa. 1, 2, 3 Approximately 20-40% of patients inappropriately receive oral antibiotics, and most prescribed oral antibiotics are inactive against P. aeruginosa and S. aureus (the causative pathogens in 98% of cases). 1, 3

Reserve systemic antibiotics for these specific circumstances ONLY: 1, 2, 3

• Extension of infection beyond the ear canal 1, 2, 3
• Diabetes mellitus or immunocompromised status 1, 2, 3, 8
• Topical therapy cannot reach infected area 1, 2
• Treatment failure after 48-72 hours 1, 2

When systemic antibiotics are indicated, use fluoroquinolones (e.g., ciprofloxacin) for coverage against Pseudomonas aeruginosa and Staphylococcus aureus. 1, 3

Special Populations Requiring Modified Management

Diabetic or Immunocompromised Patients:

• Monitor carefully for necrotizing otitis externa, which can present initially with symptoms similar to uncomplicated otitis externa 1, 8, 9
• Consider adding systemic antibiotics in addition to topical therapy 1, 2, 3
• More susceptible to otomycosis (fungal infection) 1, 3
• Use atraumatic suctioning instead of aggressive irrigation 1

Suspected Fungal Otitis Externa (Otomycosis):

• Treat with topical antifungals and debridement 1
• Avoid antibacterial drops that promote fungal overgrowth 1
• Consider in patients with diabetes or those failing antibacterial therapy 1

When to Reassess or Consider Treatment Failure

Reassess within 48-72 hours if no improvement occurs. 1, 2 Reasons for treatment failure include:

• Inadequate drug delivery due to canal obstruction 1, 2
• Poor adherence to therapy (patients overadminister when pain is greatest, underadminister as symptoms resolve) 1
• Fungal co-infection 1, 2
• Allergic contact dermatitis from topical agents 1, 2
• Incorrect diagnosis 1, 2

Patient Education and Activity Restrictions

• Keep ear dry during treatment—cover ear canal with earplug or petroleum jelly-coated cotton before showering 1, 2
• Complete full 7-day course even if symptoms resolve early 1, 2
• If you taste the eardrops, notify physician immediately—this indicates tympanic membrane perforation 1
• Return for reassessment if symptoms don't improve within 48-72 hours 1, 2
• Never use ear candles—no proven efficacy and can cause harm including canal obstruction, hearing loss, and tympanic membrane perforation 1, 2

Common Pitfalls to Avoid

• Overuse of oral antibiotics for uncomplicated cases 1, 2
• Using ototoxic aminoglycoside preparations when tympanic membrane integrity is compromised 1, 2
• Inadequate pain management 1, 2
• Failure to remove debris before administering drops 1, 2
• Missing fungal infections, especially in diabetic patients or those failing antibacterial therapy 1, 2
• Prescribing antibiotics with inadequate coverage against Pseudomonas aeruginosa 1