What is the treatment for an adult with an ear infection?

Treatment for Adult Ear Infection

Topical antibiotic drops are the definitive first-line treatment for uncomplicated acute otitis externa (swimmer's ear) in adults, NOT oral antibiotics. 1, 2

Distinguish the Type of Ear Infection First

• Acute otitis externa (swimmer's ear) is the most common ear infection in adults, affecting approximately 10% of people during their lifetime 3
• Key diagnostic features include ear pain worsened by moving the tragus or pinna, ear canal swelling and redness, discharge, and often a history of swimming or ear canal trauma 1, 3
• Acute otitis media (middle ear infection) is less common in adults and presents with ear pain but WITHOUT tenderness when moving the outer ear 4

Essential Pre-Treatment Assessment

Before prescribing any treatment, assess for these critical modifying factors that fundamentally change management 1, 2:

• Tympanic membrane integrity: If perforated, non-intact, or uncertain, use ONLY non-ototoxic fluoroquinolones (ofloxacin 0.3% or ciprofloxacin) to avoid ototoxicity 2, 3
• Diabetes or immunocompromised state: Higher risk for necrotizing otitis externa and fungal infections; may require systemic antibiotics even for uncomplicated cases 2, 3
• Extension beyond ear canal: Requires systemic antibiotics 1, 2

First-Line Treatment for Uncomplicated Otitis Externa

Topical Antibiotic Therapy

All FDA-approved topical antibiotic drops achieve 65-90% clinical cure rates within 7-10 days, with no consistent advantage of one agent over another 2, 5:

• When tympanic membrane is intact: Any FDA-approved topical preparation is acceptable 2
• When tympanic membrane is perforated or uncertain: Use ONLY fluoroquinolones (ofloxacin 0.3% or ciprofloxacin 0.2%) 2, 3
• Topical antibiotics deliver 100-1000 times higher drug concentrations at the infection site compared to oral antibiotics 2, 6

Critical Pre-Treatment Step: Aural Toilet

Before administering any drops, the ear canal MUST be cleared of debris, cerumen, and inflammatory material to ensure medication reaches infected tissues 1, 2, 6:

• Use gentle suction, dry mopping, or irrigation with body-temperature water 2
• Exception: In diabetic or immunocompromised patients, avoid aggressive irrigation as it can trigger necrotizing otitis externa; use atraumatic suctioning under microscopic guidance instead 2, 6
• Consider placing a compressed cellulose wick if severe edema prevents drop entry 2

Proper Drop Administration Instructions

• Warm the bottle in hands for 1-2 minutes to prevent dizziness 2
• Have someone else administer drops if possible (only 40% of patients self-administer correctly) 2
• Lie with affected ear upward, fill canal completely with drops, maintain position for 3-5 minutes 2
• Apply gentle to-and-fro movement of pinna or tragal pumping to eliminate trapped air 2
• Keep ear dry during treatment; use petroleum jelly-coated cotton or earplug before showering 2

Treatment Duration

• Minimum 7 days, even if symptoms resolve earlier 2
• If symptoms persist beyond 7 days, continue drops until resolution for maximum of 7 additional days (total 14 days maximum) 2

Pain Management

Pain assessment and appropriate analgesics are essential for all patients 1, 2:

• Prescribe acetaminophen or NSAIDs based on pain severity 2, 3
• NSAIDs administered during acute phase significantly reduce pain compared to placebo 2
• Pain typically improves within 48-72 hours of starting topical therapy 2, 3
• Avoid topical anesthetic drops (benzocaine): Not FDA-approved for active ear canal infections and can mask delayed treatment response 2

When Systemic Antibiotics ARE Indicated

Oral antibiotics should NOT be prescribed for uncomplicated otitis externa 1, 2. Reserve systemic antibiotics for:

• Extension of infection beyond the ear canal (periauricular swelling) 1, 2, 3
• Diabetes mellitus or immunocompromised state 1, 2, 3
• When topical therapy cannot reach the infected area 1, 2
• Treatment failure after 48-72 hours of appropriate topical therapy 2

When systemic antibiotics are required, use fluoroquinolones (ciprofloxacin oral) for coverage against Pseudomonas aeruginosa and Staphylococcus aureus 2, 6, 3

Treatment for Acute Otitis Media (Middle Ear Infection)

If acute otitis media is confirmed (middle ear effusion, bulging tympanic membrane, WITHOUT tenderness when moving outer ear):

• Amoxicillin 80-90 mg/kg/day (maximum 500 mg/dose) divided into 3 doses is first-line 7, 4
• Amoxicillin-clavulanate 1.75 g amoxicillin/250 mg clavulanate per day for mild-moderate disease in adults 3, 7
• Adequate analgesia should be provided based on pain severity 4

Expected Timeline and When to Reassess

• Symptoms should improve within 48-72 hours of starting appropriate therapy 2, 6, 3
• Reassess if no improvement by 48-72 hours 2, 3
• Consider treatment failure causes: inadequate drug delivery due to canal obstruction, poor adherence, fungal co-infection, allergic contact dermatitis (especially to neomycin), or incorrect diagnosis 2, 3

Special Considerations for High-Risk Patients

Diabetic or Immunocompromised Patients

• More susceptible to otomycosis and necrotizing otitis externa 2, 3
• Consider adding systemic fluoroquinolones even for uncomplicated cases 2, 6
• Monitor carefully for necrotizing otitis externa, which can present initially with symptoms similar to uncomplicated otitis externa 2
• Avoid aggressive irrigation; use atraumatic suctioning instead 2, 6

Suspected Fungal Infection (Otomycosis)

• Suspect if white fuzzy exudate with pruritus, discharge, or treatment failure after antibacterial therapy 2
• Treat with thorough but gentle debridement of fungal debris and topical antifungal preparations 3-4 times daily for 7-10 days 2
• Avoid antibacterial drops that may promote fungal overgrowth 2

Critical Pitfalls to Avoid

• Prescribing oral antibiotics for uncomplicated otitis externa (20-40% of patients inappropriately receive them; increases antibiotic resistance without clinical benefit) 1, 2, 3
• Using aminoglycoside-containing drops (neomycin) when tympanic membrane integrity is unknown (risk of ototoxicity) 2, 3
• Failing to clean ear canal debris before administering drops (medication won't reach infection site) 2, 6
• Inadequate pain management (pain can be severe and requires appropriate analgesia) 2, 6
• Missing fungal infections, especially in diabetics or those failing antibacterial therapy 2, 3
• Missing necrotizing otitis externa in diabetic or immunocompromised patients (life-threatening condition requiring aggressive treatment) 3
• Using neomycin-containing preparations in patients with contact dermatitis history (5-15% of patients with chronic otitis externa are hypersensitive to neomycin) 2

When to Refer to Otolaryngology

• Symptoms persist beyond 7 days despite appropriate treatment 3
• Hearing loss develops or persists 3
• Excessive cerumen cannot be safely removed 3
• Recurrent infections occur 3
• Suspected necrotizing otitis externa 3