What is the best treatment approach for a patient with congested ears?

Treatment of Congested Ears

The best treatment approach depends on the underlying cause: for acute otitis externa (swimmer's ear), use topical antibiotic drops like ofloxacin; for otitis media with effusion (fluid behind the eardrum), watchful waiting for 3 months is recommended; for Eustachian tube dysfunction causing pressure/fullness, oral decongestants like pseudoephedrine may provide temporary relief. 1, 2, 3

Identifying the Cause of Ear Congestion

The sensation of "congested ears" requires distinguishing between several distinct conditions:

• Acute otitis externa (swimmer's ear): Presents with ear canal inflammation, tenderness when touching the tragus or pulling the pinna, canal edema, erythema, or discharge developing over less than 48 hours 1
• Otitis media with effusion: Fluid behind an intact eardrum, diagnosed by pneumatic otoscopy showing decreased tympanic membrane mobility, often without pain 2
• Eustachian tube dysfunction: Sensation of fullness, pressure, or "plugged" ears, often worsening with altitude changes or upper respiratory infections 2, 4
• Cerumen impaction: Visible wax obstruction on examination 1

Treatment Algorithm by Diagnosis

For Acute Otitis Externa (Swimmer's Ear)

Topical antibiotic drops are the definitive first-line treatment, NOT oral antibiotics. 1

• First-line topical therapy: Ofloxacin 0.3% otic solution achieves 65-90% clinical cure rates within 7-10 days and is safe even when tympanic membrane integrity is uncertain 1
• Essential pre-treatment step: Remove debris, cerumen, and inflammatory material from the ear canal using gentle suction or dry mopping to ensure medication reaches infected tissues 1, 5
• Proper administration technique: Warm the bottle in hands for 1-2 minutes, lie with affected ear upward, fill the canal completely with drops, maintain position for 3-5 minutes, and apply gentle tragal pumping to eliminate trapped air 1, 5
• Pain management: Prescribe acetaminophen or NSAIDs based on severity; pain typically improves within 48-72 hours 1, 5
• Treatment duration: Continue drops for minimum 7 days even if symptoms resolve earlier 1
• Keep ear dry: Cover ear canal with petroleum jelly-coated cotton before showering; avoid swimming during treatment 1, 5

When to use oral antibiotics (NOT for uncomplicated cases): Reserve systemic antibiotics only for infection extending beyond the ear canal, diabetic or immunocompromised patients, or when topical therapy cannot reach the infected area 1

For Otitis Media with Effusion (Fluid Behind Eardrum)

Watchful waiting for 3 months is the recommended approach for children without risk factors. 2

• Do NOT use: The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends against antibiotics, antihistamines, decongestants, or steroids for treating otitis media with effusion 2
• Obtain hearing test: If effusion persists ≥3 months or in at-risk children (those with developmental delays, learning difficulties, or baseline sensory/cognitive impairments) 2
• Reevaluate at 3-6 month intervals: Continue surveillance until effusion resolves, significant hearing loss is identified, or structural abnormalities are suspected 2
• Consider tympanostomy tubes: Only after 3 months of persistent bilateral effusion with documented hearing loss or in at-risk children 2

For Eustachian Tube Dysfunction/Nasal Congestion

Oral decongestants provide temporary symptomatic relief but do not alter disease course. 3, 6

• Pseudoephedrine 30-60 mg: FDA-approved for temporarily relieving sinus congestion, pressure, and nasal congestion due to common cold or allergies 3
• Intranasal corticosteroids: May be used for chronic rhinosinusitis symptoms requiring long-term management; mometasone furoate or fluticasone propionate preferred for once-daily dosing and negligible bioavailability 2
• Duration of decongestant use: Topical nasal decongestants should NEVER be continued for more than a few days to avoid rebound congestion 6
• Oral decongestants: Safer for chronic use than topical agents when Eustachian tube decongestion is required 6

Avoid habitual Valsalva maneuvers: Chronic forceful Valsalva to "pop" ears can cause serious complications including pneumatization of skull bones and epidural air 7

Common Pitfalls to Avoid

• Prescribing oral antibiotics for uncomplicated otitis externa: 20-40% of patients inappropriately receive oral antibiotics that are often inactive against Pseudomonas aeruginosa, the primary pathogen 1
• Using ototoxic ear drops when tympanic membrane integrity is uncertain: Always use non-ototoxic fluoroquinolones (ofloxacin or ciprofloxacin) if perforation is possible 1
• Treating otitis media with effusion with antibiotics, antihistamines, or decongestants: These medications have no proven benefit and expose patients to unnecessary adverse effects 2
• Failing to remove ear canal debris before administering drops: Only 40% of patients self-administer drops correctly; medication cannot reach infected tissues if debris obstructs the canal 1, 5
• Inadequate pain management: Ear pain can be severe and requires appropriate analgesics, not just topical therapy 1, 5
• Continuing topical nasal decongestants beyond a few days: This causes rebound congestion (rhinitis medicamentosa) 6

When to Reassess or Refer

• No improvement within 48-72 hours of starting appropriate topical therapy for otitis externa warrants reassessment for treatment failure causes: inadequate drug delivery, poor adherence, fungal co-infection, allergic contact dermatitis, or incorrect diagnosis 1
• Otitis media with effusion persisting ≥3 months requires hearing evaluation and consideration for ENT referral 2
• Red flags requiring urgent evaluation: Extension of infection beyond ear canal, fever, periauricular swelling, facial nerve weakness, or severe systemic symptoms 1