Treatment for Pediatric Patient with Tympanostomy Tubes, Ear Drainage, AND Streptococcal Pharyngitis
When a child with tympanostomy tubes and ear drainage also has concurrent streptococcal pharyngitis, you must treat BOTH conditions: use topical antibiotic ear drops (ofloxacin or ciprofloxacin-dexamethasone) for the ear drainage AND add oral antibiotics (amoxicillin or azithromycin) specifically for the strep throat. 1, 2
Why Oral Antibiotics Are Required in This Scenario
The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that systemic antibiotic therapy IS appropriate when "concurrent bacterial infection (eg, sinusitis, pneumonia, or streptococcal pharyngitis) is present," even when treating tympanostomy tube otorrhea. 1
This represents one of the specific exceptions to the general rule that oral antibiotics are unnecessary for most ear infections with tubes. 1, 2
Specific Treatment Regimen
For the Ear Drainage (Tympanostomy Tube Otorrhea):
Topical therapy: Ofloxacin 0.3% otic solution, 5 drops (0.25 mL) into the affected ear twice daily for 10 days for children ages 1-12 years. 3
Alternative: Ciprofloxacin-dexamethasone otic solution with the same dosing schedule. 1, 2
Administration technique: Clean the ear canal first with a cotton-tipped swab dipped in hydrogen peroxide, then instill drops and "pump" the tragus 4 times to facilitate drug delivery into the middle ear. 1, 3
Prevent water entry into the ear canal during active drainage. 1
For the Streptococcal Pharyngitis:
First-line oral therapy: Amoxicillin at standard dosing (typically 50 mg/kg/day divided twice daily) for 10 days. 1, 4
Alternative for penicillin-allergic patients: Azithromycin, though the FDA label notes that penicillin remains the drug of choice for Streptococcus pyogenes and that some strains are resistant to azithromycin. 4
Recent research suggests shorter courses (5-7 days) may be effective for strep throat, but 10 days remains the standard recommendation for rheumatic fever prevention. 5
Clinical Reasoning
The topical ear drops alone will NOT treat the streptococcal pharyngitis because they achieve high concentrations only at the site of infection (the middle ear), not systemically. 1
Conversely, oral antibiotics recommended for strep throat (amoxicillin or amoxicillin-clavulanate) have inferior efficacy for tympanostomy tube otorrhea compared to topical therapy, with clinical cure rates of only 30-67% versus 77-96% for topical drops. 1
Therefore, dual therapy addresses both infections optimally using the most effective route for each condition.
Important Caveats
Do NOT use aminoglycoside-containing ear drops (commonly used for otitis externa) in patients with tympanostomy tubes due to ototoxicity risk. 1
Limit topical ear drop therapy to no more than 10 days to avoid yeast infections of the ear canal. 1, 2
If ear drainage persists beyond 7 days despite treatment, contact the otolaryngologist for reassessment. 2
The child can typically return to school 12-24 hours after starting amoxicillin for strep throat if afebrile and improved, even while continuing topical ear drop therapy. 6