What is the appropriate treatment for a patient presenting with yellow drainage from the ear, diminished hearing, and no pain?

Yellow Ear Drainage Without Pain and Diminished Hearing

The appropriate treatment is topical fluoroquinolone antibiotic ear drops (ofloxacin or ciprofloxacin-dexamethasone) administered twice daily for 7-10 days, as this achieves cure rates of 77-96% compared to only 30-67% with oral antibiotics. 1, 2

Initial Diagnostic Considerations

The presentation of yellow drainage with hearing loss but no pain suggests either:

• Tympanostomy tube otorrhea (TTO) if the patient has tubes in place 1, 2
• Chronic suppurative otitis media with tympanic membrane perforation 3
• Acute otitis externa (swimmer's ear), though this typically causes pain 1

Direct visualization of the tympanic membrane with pneumatic otoscopy is essential to determine if there is a perforation, tube in place, or intact membrane with external canal infection. 4, 5

First-Line Treatment Protocol

Topical Antibiotic Therapy (Preferred)

Topical fluoroquinolone drops are superior to oral antibiotics because they deliver 1000-fold higher drug concentrations at the infection site and provide better coverage of common pathogens including Pseudomonas aeruginosa, Staphylococcus aureus, and Streptococcus pneumoniae. 2

Specific dosing regimens: 3

• For patients ≥13 years with otitis externa: 10 drops (0.5 mL ofloxacin) once daily for 7 days
• For patients 6 months to 13 years with otitis externa: 5 drops (0.25 mL ofloxacin) once daily for 7 days
• For patients 1-12 years with tubes (TTO): 5 drops twice daily for 10 days
• For patients ≥12 years with perforated tympanic membrane: 10 drops twice daily for 14 days

Administration technique is critical: 1, 3

• Warm the bottle in hand for 1-2 minutes to avoid dizziness
• Patient lies with affected ear upward
• Instill drops, then pump the tragus 4 times to facilitate penetration
• Maintain position for 5 minutes

Aural Toilet

Remove visible drainage at the ear canal opening using cotton-tipped swabs dipped in hydrogen peroxide or warm water, or gentle suction with an infant nasal aspirator. 1 Do NOT insert objects deep into the canal. 3

When Oral Antibiotics Are NOT Indicated

Oral antibiotics should NOT be used as first-line therapy for uncomplicated ear drainage, as they achieve only 30-67% cure rates versus 77-96% with topical drops. 1, 2

Exceptions requiring oral antibiotics include: 1, 2

• Cellulitis of the pinna or adjacent skin
• Signs of severe systemic infection
• Drainage persisting beyond 7-10 days despite appropriate topical therapy
• Patient is severely ill with concurrent bacterial infection

Water Precautions During Treatment

Strict water avoidance is essential: 1, 2

• Use cotton saturated with Vaseline to cover the ear canal opening during bathing or hair washing
• No swimming until drainage completely stops
• Avoid inserting objects or cotton swabs into the canal

Expected Clinical Course and Follow-Up

Improvement should occur within 48-72 hours of starting appropriate topical therapy, with complete resolution typically within 7-10 days. 2

Refer to otolaryngology if: 1, 2

• Drainage continues beyond 7 days despite appropriate topical therapy
• Frequent recurrent drainage episodes
• Hearing loss persists after drainage resolves
• Cannot visualize the tympanic membrane due to obstructing debris

Common Pitfalls to Avoid

Do not prescribe oral antibiotics first - this is the most common error and results in significantly lower cure rates. 1, 2

Do not use ototoxic drops (aminoglycosides like neomycin) if tympanic membrane perforation cannot be excluded; only fluoroquinolones are safe for middle ear exposure. 4

Do not skip the tragus-pumping technique - this is essential for drug delivery through tubes or perforations into the middle ear space. 1, 3

Do not use antibiotic eardrops for more than 10 days continuously to avoid yeast infections of the ear canal. 1

Addressing the Hearing Loss

The diminished hearing is likely due to fluid/debris in the ear canal or middle ear space and should resolve with treatment of the infection. 2 If hearing loss persists after drainage resolves, obtain age-appropriate audiometry to exclude underlying sensorineural hearing loss or chronic middle ear effusion. 5