Treatment of Ear Infection with Tympanostomy Tube and Drainage
For a patient with a tympanostomy tube and visible ear drainage, use topical antibiotic ear drops (ofloxacin or ciprofloxacin-dexamethasone) twice daily for 7-10 days as first-line therapy—oral antibiotics are NOT needed for most cases. 1, 2
Primary Treatment Algorithm
First-Line Therapy: Topical Antibiotics Alone
- Administer ofloxacin 0.3% otic solution OR ciprofloxacin-dexamethasone drops directly into the ear canal twice daily for up to 10 days. 1, 3, 2
- For pediatric patients ages 1-12 years with tympanostomy tubes: use 5 drops (0.25 mL) of ofloxacin twice daily for 10 days. 4
- Topical therapy achieves dramatically superior clinical cure rates of 77-96% compared to only 30-67% with oral antibiotics. 1, 2
Critical Administration Technique
- "Pump" the tragus (flap of skin in front of the ear canal) 4 times after placing drops to facilitate penetration through the tube into the middle ear space. 1, 2, 5
- Warm the bottle in your hand for 1-2 minutes before instillation to avoid dizziness from cold solution. 4
- Have the patient lie with the affected ear upward and maintain this position for 5 minutes after drop administration. 4
- Clean the ear canal first by removing visible drainage with a cotton-tipped swab dipped in hydrogen peroxide or warm water. 1, 2
Why Topical Therapy is Superior
The evidence strongly favors topical over systemic antibiotics for several reasons:
- Higher drug concentrations are delivered directly to the infection site through the tube. 3, 2
- Better pathogen coverage, particularly for Pseudomonas aeruginosa and Staphylococcus aureus, which commonly cause infections in tubes after water exposure. 1, 3, 2
- Superior bacterial eradication rates (96% vs 67% for oral antibiotics). 1, 6
- Avoids systemic side effects—treatment-related adverse events occur in only 6% with topical therapy versus 31% with oral antibiotics. 6
When Oral Antibiotics ARE Indicated
Oral antibiotics (amoxicillin or amoxicillin-clavulanate) should be reserved for specific circumstances only: 1, 2
- The child appears very ill or toxic
- The infection does not resolve after completing the full 7-10 day course of topical drops
- The child has another concurrent indication requiring systemic antibiotics
- The tube is blocked/non-functioning (treat as if no tube is present)
Supportive Care Measures
- Use acetaminophen or ibuprofen for pain or fever management. 2
- Prevent water entry during treatment by placing cotton saturated with Vaseline over the ear canal opening during bathing. 1
- Do NOT allow swimming until drainage completely stops. 1
- Most children do not experience pain or fever when the tube is functioning properly and draining the infection. 1
Important Caveats and Pitfalls
Duration Limits
- Never use antibiotic ear drops for more than 10 days at a time to avoid yeast infections of the ear canal. 1, 2
- Do not use drops frequently or continuously. 1
When to Refer to Otolaryngology
Call the ear specialist if: 1, 2
- Ear drainage continues for more than 7 days despite proper treatment
- Drainage occurs frequently/recurrently
- The primary doctor cannot visualize the tube in the ear
- The child has hearing loss, continued ear infections, or persistent ear pain
- Excessive wax buildup prevents visualization or treatment
Common Misconception About Water Exposure
While water precautions are recommended during active infection, swimming without earplugs does NOT increase infection rates in children with tubes (16% infection rate without earplugs vs 30% with earplugs). 7 However, during active drainage, water should be avoided until resolution. 1