What is the treatment for a 3-year-old with purulent discharge from the ear?

Treatment of Purulent Ear Discharge in a 3-Year-Old

Topical antibiotic ear drops—specifically ciprofloxacin or ciprofloxacin-dexamethasone—applied twice daily for 7-10 days are the definitive first-line treatment for a 3-year-old with purulent ear discharge. 1

Why Topical Therapy is Superior

The evidence strongly favors topical over oral antibiotics for purulent ear discharge:

• Clinical cure rates are dramatically higher with topical therapy: 77-96% versus only 30-67% with oral antibiotics 1
• Topical drops deliver antibiotic concentrations up to 1000-fold higher at the infection site compared to systemic therapy 1
• The combination of ciprofloxacin-dexamethasone is superior to antibiotics alone when available 1

Proper Application Technique

To maximize effectiveness:

• Clean the ear canal first by removing visible discharge with a cotton-tipped swab dipped in hydrogen peroxide or warm water 1
• Pull the ear gently backward and upward to straighten the canal 2
• Instill drops twice daily and "pump" the tragus several times after application to help medication penetrate 1, 2
• Prevent water entry during treatment using cotton saturated with Vaseline to cover the ear canal opening; no swimming until drainage stops 1, 2

When Oral Antibiotics ARE Indicated

Reserve systemic antibiotics for specific situations only:

• The child appears very ill with high fever (≥39°C), severe otalgia, or toxic appearance 1, 3
• Cellulitis of the pinna or adjacent skin is present 1
• Concurrent bacterial infection exists (sinusitis, pneumonia, streptococcal pharyngitis) 1
• Topical therapy fails after 7 days 1, 2

If oral antibiotics are needed, amoxicillin at 80-90 mg/kg/day in two divided doses is first-line 4, or amoxicillin-clavulanate if the child has taken amoxicillin in the past 30 days or has purulent conjunctivitis 1, 4

Critical Pitfalls to Avoid

• Do NOT use topical antibiotics for more than 10 days continuously to prevent yeast infections of the ear canal 1, 2
• Do NOT use aminoglycoside-containing ear drops if tympanic membrane perforation is suspected due to ototoxicity risk; quinolones are safe 1, 2
• Do NOT substitute oral antibiotics as first-line therapy when topical options are appropriate 1
• Do NOT insert objects deep into the canal during cleaning 2

When to Escalate Care

Contact an otolaryngologist if:

• Ear drainage continues for more than 7 days despite appropriate topical therapy 1, 2
• The child develops hearing loss, continued ear pain, or discomfort 1, 2
• Drainage occurs frequently or recurs 1, 2
• Excessive wax build-up obstructs visualization or treatment 1, 2

Expected Timeline

• The child should begin improving within 48 hours of starting treatment 2
• Standard treatment duration is 7-10 days for uncomplicated infections 1, 2
• If no improvement occurs by 48-72 hours, reassess for obstructing debris in the canal or consider culture-directed therapy 1, 2

Special Consideration: Tympanostomy Tubes

If the child has tympanostomy tubes in place, the purulent discharge likely represents acute otorrhea draining through the tube—this is actually the tube functioning as intended 1. The same topical antibiotic approach applies, with even stronger evidence supporting topical over systemic therapy in this population 1.