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, NOT oral antibiotics, with clinical cure rates of 65-90% within 7-10 days. 1

Initial Management Steps

Before prescribing any medication, perform aural toilet to remove debris, cerumen, and inflammatory material from the ear canal—this is essential because medication cannot reach infected tissues if the canal is obstructed. 1, 2 Use gentle suction, dry mopping, or irrigation with body-temperature water, saline, or hydrogen peroxide. 1

Critical caveat: In diabetic or immunocompromised patients, avoid aggressive irrigation as this can trigger necrotizing otitis externa—use atraumatic suctioning under microscopic guidance instead. 1

If severe canal edema prevents drop entry or you cannot visualize most of the tympanic membrane, place a compressed cellulose wick that expands when exposed to moisture, facilitating drug delivery. 1

Topical Antimicrobial Selection

Your choice depends on tympanic membrane integrity:

For Intact Tympanic Membrane (or Confirmed Intact)

Any FDA-approved topical preparation is acceptable, including: 1

• Neomycin/polymyxin B/hydrocortisone (most cost-effective)
• Ofloxacin 0.3%
• Ciprofloxacin 0.2%

However, avoid neomycin-containing preparations if the patient has any history of contact dermatitis—neomycin causes allergic reactions in 5-15% of patients with chronic external otitis. 1

For Perforated Tympanic Membrane, Tympanostomy Tubes, or Uncertain Integrity

Use ONLY non-ototoxic fluoroquinolone preparations: 1, 2, 3, 4

• Ofloxacin 0.3%: 5 drops once daily for 7 days (ages 6 months-12 years) or 10 drops once daily for 7 days (≥13 years) 3
• Ciprofloxacin 0.2%: 0.25 mL (one single-dose container) twice daily for 7 days 4

Never use aminoglycoside-containing drops (neomycin, gentamicin) when tympanic membrane integrity is compromised due to ototoxicity risk. 1, 2

Why Topical Therapy Works Better

Topical antibiotics deliver concentrations 100-1000 times higher than systemic therapy at the infection site and provide superior coverage against Pseudomonas aeruginosa (the causative pathogen in 20-60% of cases) and Staphylococcus aureus (10-70% of cases). 1, 5 Randomized trials show topical antibiotics achieve clinical cure rates of 77-96% versus only 30-67% for oral antibiotics. 1

Pain Management

Assess pain severity and prescribe appropriate analgesics immediately—otitis externa pain can be severe because the periosteum of the underlying bone is highly sensitive. 1, 5

• Mild-to-moderate pain: Acetaminophen or NSAIDs 1, 5
• Severe pain: Consider short-term opioid-containing analgesics for the initial 48-72 hours 2, 5

Pain typically improves within 48-72 hours of starting topical therapy. 1, 2 Do NOT use topical anesthetic drops (benzocaine)—they are not FDA-approved for active ear canal infections and can mask delayed treatment response. 1

Proper Drop Administration (Critical for Success)

Only 40% of patients self-administer drops correctly during the first 3 days—improper technique is a common cause of treatment failure. 1 Instruct patients to:

1. Warm the bottle in hands for 1-2 minutes to prevent dizziness 1, 3, 4
2. Lie with affected ear upward 1, 3, 4
3. Fill the ear canal with prescribed number of drops 1
4. Maintain position for 3-5 minutes to allow penetration 1, 3
5. Apply gentle to-and-fro movement of the pinna or tragal pumping to eliminate trapped air 1
6. Have someone else administer drops if possible—this significantly improves adherence 1

Keep the ear dry during treatment—cover the ear canal with an earplug or petroleum jelly-coated cotton before showering. 1, 2

When to Use Systemic Antibiotics

Oral antibiotics should NOT be used as initial therapy for uncomplicated otitis externa. 1, 2, 5 Approximately 20-40% of patients inappropriately receive oral antibiotics, and most prescribed oral antibiotics are inactive against P. aeruginosa. 1

Reserve systemic antibiotics for these specific circumstances only: 1, 2, 5

• Extension of infection beyond the ear canal (periauricular swelling)
• Diabetes mellitus
• Immunocompromised status
• Topical therapy cannot reach the infected area
• Treatment failure after 48-72 hours

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

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
• Consider adding systemic antibiotics even for uncomplicated cases 1, 2
• Higher susceptibility to otomycosis (fungal infection) 1, 5
• Use atraumatic suctioning instead of irrigation 1

Suspected Fungal Otitis Externa (Otomycosis)

Look for white fuzzy exudate with pruritus and discharge. 1 Treatment requires:

• Thorough but gentle debridement of fungal debris 1
• Topical antifungal preparations 3-4 times daily for 7-10 days 1
• Avoid antibacterial drops that promote fungal overgrowth 1, 2

Treatment Failure: When to Reassess

Reassess within 48-72 hours if no improvement occurs. 1, 2 Common causes of treatment failure include: 1

• Inadequate drug delivery due to canal obstruction (debris not removed)
• Poor adherence to therapy (improper drop administration)
• Allergic contact dermatitis from topical agents (especially neomycin or hydrocortisone—occurs in 13-30% with chronic use)
• Fungal co-infection (especially in diabetics or after antibiotic use)
• Incorrect diagnosis

If symptoms persist beyond 7 days despite appropriate therapy, continue drops until resolution for a maximum of 7 additional days (total 14 days maximum). 1

Common Pitfalls to Avoid

• Overusing oral antibiotics for uncomplicated cases 1, 2
• Using ototoxic preparations (aminoglycosides) when tympanic membrane integrity is compromised 1, 2
• Inadequate pain management 1, 2
• Failing to remove debris before administering drops 1, 2
• Missing fungal infections, especially in diabetics or treatment failures 1, 2
• Using ear candles—they have no proven efficacy and can cause harm including ear canal obstruction, hearing loss, and tympanic membrane perforation 1, 2

Expected Clinical Course

• Pain improvement: Within 48-72 hours 1, 2
• Clinical resolution: 65-90% of patients within 7-10 days 1, 5
• Complete full 7-day course even if symptoms resolve earlier to prevent relapse 1, 2

If the patient tastes the eardrops, this indicates tympanic membrane perforation—switch immediately to a non-ototoxic fluoroquinolone preparation. 1