Can Maxitrol Be Used in the Ear?
Maxitrol (neomycin/polymyxin B/dexamethasone) can be used in the ear for acute otitis externa, but ONLY if the tympanic membrane is intact—it should never be used if there is a perforation, tympanostomy tubes, or uncertain membrane status due to significant ototoxicity risk. 1, 2
When Maxitrol Is Appropriate
Intact tympanic membrane with acute otitis externa: Maxitrol is an acceptable topical treatment option for uncomplicated AOE when the eardrum is confirmed to be intact, delivering antimicrobial concentrations 100-1000 times higher than systemic therapy. 1
Equivalent efficacy to other combinations: Clinical cure rates for antibiotic-steroid combinations (including neomycin/polymyxin B/dexamethasone) range from 65-90% regardless of which corticosteroid is used, with no meaningful differences in outcomes based on steroid type. 2
Proper administration technique: Have the patient lie with the affected ear upward, administer drops along the side of the ear canal until filled, and maintain this position for 3-5 minutes with gentle to-and-fro movement of the pinna to eliminate trapped air. 1
Critical Contraindications and Safety Concerns
Non-intact tympanic membranes are an absolute contraindication: Both neomycin and polymyxin B are potentially ototoxic when they contact the middle ear, causing sensorineural hearing loss. 1, 2, 3, 4
Documented ototoxicity with middle ear exposure: Studies demonstrate that neomycin and polymyxin B in concentrations found in commercial otic drops induce cochlear damage when applied to the middle ear space, with the degree of damage related to concentration and duration. 4
Chronic otitis media patients show worsening hearing: Patients with chronic otitis media treated with neomycin/polymyxin B/dexamethasone mixtures demonstrated a relationship between treatment duration and sensorineural hearing loss compared to dexamethasone-only controls. 3
Important Caveats and Pitfalls
High rate of contact dermatitis: Neomycin causes contact sensitivity in 13-30% of patients with chronic otitis externa, presenting as worsening symptoms despite treatment—if no improvement occurs within 48-72 hours, consider allergic contact dermatitis and switch to a fluoroquinolone preparation. 5, 1, 2
Not first-line if membrane status uncertain: If you cannot clearly visualize an intact tympanic membrane, use only non-ototoxic fluoroquinolones (such as ciprofloxacin/dexamethasone) instead. 2
Fungal superinfection risk: Fungal involvement may develop after treatment with topical antibiotics, particularly in diabetic or immunocompromised patients who require special consideration. 1
Alternative Considerations
Fluoroquinolone combinations are safer with uncertain membranes: Ciprofloxacin/dexamethasone demonstrates superior clinical cure rates (90.9% vs 83.9%) and microbiologic eradication (94.7% vs 86.0%) compared to neomycin/polymyxin B/hydrocortisone, without ototoxicity concerns. 6
Once-daily fluoroquinolones improve compliance: Ofloxacin once daily shows equivalent efficacy to neomycin/polymyxin B/hydrocortisone four times daily (93.8% vs 94.7% cure rates) without the ototoxicity risk, making it preferable for pediatric patients. 7