What is the management of otitis externa (inflammation of the external ear)?

From the Guidelines

Management of otitis externa involves a comprehensive approach focusing on pain relief, inflammation reduction, and infection control, with topical antimicrobial drops being the primary treatment, as supported by the clinical practice guideline published in 2014 by the American Academy of Otolaryngology—Head and Neck Surgery Foundation 1. The approach should begin with cleaning the ear canal with gentle suction or irrigation to remove debris, followed by application of topical antimicrobial drops.

• For mild to moderate cases, use acidifying solutions like 2% acetic acid or combination antibiotic-steroid drops such as ciprofloxacin 0.3% with dexamethasone 0.1%, applying 3-4 drops three times daily for 7-10 days.
• For severe cases, consider fluoroquinolone drops like ofloxacin 0.3% or ciprofloxacin 0.3%, 4 drops twice daily for 7 days. Pain management with acetaminophen or NSAIDs is essential, as most people feel better within 48 to 72 hours and have minimal or no symptoms by 7 days 1. If significant canal edema is present, insert a wick to facilitate medication delivery, removing it after 2-3 days when swelling subsides. Patients should avoid water exposure and not use cotton swabs, and oral antibiotics (such as amoxicillin-clavulanate 875/125 mg twice daily for 7-10 days) are indicated only for cases with surrounding cellulitis, immunocompromised patients, or diabetics, as stated in the clinical practice guideline 1. It is also important to note that aural toilet may be performed by the clinician with a gentle lavage using body-temperature water, saline solution, or hydrogen peroxide, but caution should be exercised in diabetic patients or immunocompromised patients with AOE, as lavage of the ear canal has been implicated as a contributing factor in malignant otitis externa 1. Overall, this approach effectively addresses otitis externa by targeting the underlying bacterial or fungal infection while reducing inflammation and allowing the ear canal epithelium to heal properly.

From the FDA Drug Label

Ciprofloxacin otic solution, 0.2% is a quinolone antimicrobial indicated for the treatment of acute otitis externa due to susceptible isolates of Pseudomonas aeruginosa or Staphylococcus aureus. The contents of one single-dose container (deliverable volume: 0.25 mL) should be instilled into the affected ear twice daily (approximately 12 hours apart) for 7 days.

The management of otitis externa with ciprofloxacin (OTIC) involves:

• Dosage: Instilling 0.25 mL of the solution into the affected ear twice daily for 7 days.
• Administration: The solution should be warmed by holding the container in the hands for at least 1 minute, and the patient should lie with the affected ear upward to facilitate penetration of the drops into the ear canal.
• Contraindications: History of hypersensitivity to ciprofloxacin.
• Warnings and Precautions: Discontinue use at the first appearance of a skin rash or any other sign of hypersensitivity, and be aware of the potential for overgrowth of nonsusceptible organisms 2.

From the Research

Management of Otitis Externa

• Otitis externa is most commonly caused by infection, usually bacterial, although occasionally fungal, and may also be associated with noninfectious systemic or local dermatologic processes 3.
• The most characteristic symptom is discomfort limited to the external auditory canal, while the most characteristic signs are erythema and swelling of the canal with variable discharge 3.
• Excessive moisture and trauma are the two most common precipitants of otitis externa, and avoidance of these precipitants is the cornerstone of prevention 3.

Treatment Options

• Thorough cleansing of the canal is essential for diagnosis and treatment, but flushing should be avoided 3.
• Acidification with a topical solution of 2 percent acetic acid combined with hydrocortisone for inflammation is effective treatment in most cases and, when used after exposure to moisture, is an excellent prophylactic 3.
• Oral ciprofloxacin has been shown to be clinically and microbiologically effective in the treatment of external bacterial otitis, with good positive dynamics of the ear canal and no major side effects 4.
• Topical ciprofloxacin/dexamethasone has been compared to neomycin/polymyxin B/hydrocortisone for the treatment of otitis externa, with ciprofloxacin/dexamethasone showing higher clinical cure rates and microbiologic eradication rates 5.
• Ciprofloxacin/dexamethasone has also been shown to provide greater pain relief and reduce inflammation and edema compared to neomycin/polymyxin B/hydrocortisone 6.

Comparison of Treatment Regimens

• A study comparing ciprofloxacin to a combination of oxytetracycline, polymyxin B, and hydrocortisone found that ciprofloxacin was effective in eradicating bacterial pathogens and improving clinical signs and symptoms 7.
• The same study found that ciprofloxacin had a higher success rate compared to the combination treatment, with 14/16 cases showing complete success compared to 5/14 cases in the combination group 7.