What is the treatment for an ear infection in adults?

Treatment of Ear Infections in Adults

Determine the Type of Ear Infection First

The most critical first step is distinguishing between otitis externa (outer ear infection) and acute otitis media (middle ear infection), as they require fundamentally different treatments. 1

• Otitis externa is far more common in adults, affecting approximately 10% during their lifetime, and presents with ear pain that worsens when pulling the tragus or pinna 1, 2
• Acute otitis media is rare in adults but involves the same bacteria as in children 3
• Tenderness when moving the tragus or pinna strongly suggests otitis externa rather than otitis media 1

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Treatment of Otitis Externa (Most Common in Adults)

First-Line Treatment: Topical Antibiotics ONLY

For uncomplicated otitis externa, topical antibiotic drops are the definitive first-line treatment—NOT oral antibiotics. 4, 1

• Topical therapy delivers 100-1000 times higher antibiotic concentrations directly to the infection site compared to oral antibiotics 4, 1
• Clinical cure rates with topical therapy: 77-96% versus only 30-67% with oral antibiotics 4
• All FDA-approved topical preparations achieve 65-90% clinical resolution within 7-10 days 4

Specific Topical Antibiotic Recommendations

If tympanic membrane integrity is uncertain or compromised (including perforated drums or tympanostomy tubes), use ONLY non-ototoxic fluoroquinolones: 4, 1

• Ofloxacin 0.3% otic solution (FDA-approved for otitis externa in adults) 5
• Ciprofloxacin 0.2% or ciprofloxacin-dexamethasone combination 3, 4

If tympanic membrane is intact, any of these options are acceptable: 4

• Ofloxacin 0.3% 4
• Ciprofloxacin-dexamethasone 3
• Neomycin/polymyxin B/hydrocortisone (avoid if history of contact dermatitis—occurs in 5-15% of patients) 4

Essential Pre-Treatment Steps

Before administering ANY drops, the ear canal MUST be cleared of debris, cerumen, and inflammatory material—otherwise medication cannot reach infected tissues. 4, 1

• Use gentle suction, dry mopping, or irrigation with body-temperature water 4
• AVOID aggressive irrigation in diabetic or immunocompromised patients—use atraumatic suctioning under microscopic guidance instead to prevent triggering necrotizing otitis externa 4
• If severe canal edema prevents drop entry, place a compressed cellulose wick that expands with moisture 4

Proper Drop Administration Technique

Only 40% of patients self-administer drops correctly—improper technique is a major cause of treatment failure. 4

• Warm bottle in hands for 1-2 minutes to prevent dizziness 4
• Have someone else administer drops if possible (significantly improves adherence) 4
• Lie with affected ear upward, fill canal with drops, maintain position for 3-5 minutes 4
• Apply gentle tragal pumping or to-and-fro pinna movement to eliminate trapped air 4

Pain Management

Pain assessment and appropriate analgesics are essential—otitis externa pain can be severe. 4, 1

• Prescribe acetaminophen or NSAIDs based on pain severity 4, 1
• Pain typically improves within 48-72 hours of starting topical therapy 4, 1
• Do NOT use topical anesthetic drops (benzocaine)—they are not FDA-approved for active infections and can mask delayed treatment response 4

Treatment Duration and Follow-Up

• Minimum 7-day course, even if symptoms resolve earlier 4
• Reassess if no improvement within 48-72 hours 4, 1
• If symptoms persist beyond 7 days, continue drops until resolution for maximum 7 additional days (14 days total maximum) 4

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When Systemic (Oral) Antibiotics ARE Indicated

Reserve oral antibiotics ONLY for these specific circumstances—NOT for uncomplicated otitis externa: 4, 1

1. Extension of infection beyond the ear canal (periauricular swelling, cellulitis) 4, 1
2. Diabetes mellitus or immunocompromised state (higher risk for necrotizing otitis externa) 4, 1
3. Topical therapy cannot reach infected area (complete canal obstruction) 4
4. Treatment failure after 48-72 hours of appropriate topical therapy 4
5. Confirmed acute otitis media (middle ear infection—rare in adults) 3, 1

Oral Antibiotic Selection When Indicated

For otitis externa requiring systemic therapy: 4, 1

• Fluoroquinolones (ciprofloxacin or levofloxacin) provide coverage against Pseudomonas aeruginosa and Staphylococcus aureus (causative organisms in 98% of cases) 4, 6

For confirmed acute otitis media in adults: 3, 1

• Amoxicillin-clavulanate is the first-line treatment 3, 1
• Standard dose: 1.75 g amoxicillin/250 mg clavulanate per day 1
• Alternative: Second-generation cephalosporins (cefuroxime-axetil) or third-generation (cefpodoxime-proxetil) 3

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High-Risk Patients Requiring Modified Management

Diabetic or immunocompromised patients require heightened vigilance for necrotizing otitis externa—a life-threatening condition. 4, 1, 2

• Consider adding systemic antibiotics (fluoroquinolones) even for seemingly uncomplicated cases 4
• Monitor carefully for signs of necrotizing otitis externa: severe pain, granulation tissue, cranial nerve involvement 4, 2
• Avoid aggressive irrigation—use atraumatic suctioning only 4
• Higher susceptibility to fungal infections (otomycosis) 4

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Treatment Failure: Causes and Management

If no improvement by 48-72 hours, consider these causes: 4, 1

1. Inadequate drug delivery (debris blocking canal, improper drop administration) 4
2. Poor adherence to therapy (patients often underadminister as symptoms improve) 4
3. Fungal co-infection (especially in diabetics or after prolonged antibiotic use)—presents with white fuzzy exudate and pruritus 4
4. Allergic contact dermatitis from topical agents (neomycin causes reactions in 5-15% of patients, hydrocortisone in 13-30%) 4
5. Incorrect diagnosis (consider referred pain from TMJ, malignancy, or other sources) 2

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Critical Pitfalls to Avoid

Approximately 20-40% of patients with otitis externa inappropriately receive oral antibiotics—this increases antibiotic resistance without clinical benefit. 4, 1

• Do NOT prescribe oral antibiotics for uncomplicated otitis externa 4, 1
• Do NOT use aminoglycoside-containing drops (neomycin) when tympanic membrane integrity is uncertain—risk of ototoxicity 4
• Do NOT fail to remove debris before administering drops—medication cannot reach infection 4
• Do NOT miss necrotizing otitis externa in diabetic/immunocompromised patients—requires aggressive treatment 1, 2
• Do NOT use ear candles—they cause harm including perforation and have never been proven effective 4

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When to Refer to Otolaryngology

Refer if: 1

• Symptoms persist beyond 7 days despite appropriate treatment
• Hearing loss develops or persists
• Recurrent infections occur
• Suspected necrotizing otitis externa
• Excessive cerumen cannot be safely removed