What is the treatment for a patient with greenish discharge in the left ear, accompanied by pain, but no fever?

Treatment for Greenish Discharge in Left Ear with Pain but No Fever

Treat this as acute otitis externa (swimmer's ear) with topical antibiotic ear drops as first-line therapy, NOT oral antibiotics. 1

Immediate Management Steps

Before prescribing any drops, the ear canal MUST be cleaned of debris and discharge to ensure medication reaches infected tissues—this is essential for treatment success. 1 Use gentle suction, dry mopping, or irrigation with body-temperature water to remove the greenish discharge and any cerumen. 1 Avoid aggressive irrigation if the patient has diabetes or is immunocompromised, as this can trigger necrotizing otitis externa. 1

First-Line Topical Antibiotic Selection

The greenish discharge strongly suggests Pseudomonas aeruginosa infection, which causes 20-60% of otitis externa cases. 1

Recommended topical antibiotics (all equally effective with 65-90% cure rates within 7-10 days): 1

• Ofloxacin 0.3% otic solution - preferred if tympanic membrane integrity is uncertain, as it is non-ototoxic 1
• Ciprofloxacin 0.2% otic drops - also non-ototoxic and safe with perforation 1
• Neomycin/polymyxin B/hydrocortisone - only if tympanic membrane is confirmed intact 1

The addition of hydrocortisone (corticosteroid) helps reduce pain and inflammation more quickly. 1

Critical Decision Point: Tympanic Membrane Status

• If you cannot visualize the tympanic membrane or integrity is uncertain: Use ONLY fluoroquinolone drops (ofloxacin or ciprofloxacin) to avoid ototoxicity 1
• If tympanic membrane is intact and visible: Any FDA-approved topical preparation is acceptable 1

Proper Administration Technique

Instruct the patient to: 1

• Warm the bottle in hands for 1-2 minutes to prevent dizziness
• Lie with affected (left) ear upward
• Fill the ear canal completely with drops
• Remain in this position for 3-5 minutes
• Apply gentle tragal pumping (press tragus in/out) to eliminate trapped air
• Have someone else administer drops if possible—only 40% of patients self-administer correctly 1

Treatment duration: Minimum 7 days, even if symptoms resolve earlier, to prevent relapse. 1

Pain Management

Prescribe appropriate analgesics based on pain severity: 1

• Acetaminophen or NSAIDs for mild-to-moderate pain 1
• Short-term opioids for severe pain during initial 48-72 hours 1

Pain typically improves within 48-72 hours of starting topical therapy. 1

When Oral Antibiotics ARE Indicated

Do NOT prescribe oral antibiotics for uncomplicated otitis externa. 1 Reserve systemic antibiotics ONLY for: 1

• Extension of infection beyond the ear canal (periauricular swelling/cellulitis)
• Diabetes mellitus or immunocompromised status
• When topical therapy cannot reach the infected area due to severe canal edema
• Treatment failure after 48-72 hours of appropriate topical therapy

If oral antibiotics are needed, use fluoroquinolones (ciprofloxacin) for Pseudomonas coverage. 1

Reassessment Criteria

Reassess within 48-72 hours if: 1

• No improvement in pain or discharge
• Symptoms worsen
• New symptoms develop (fever, periauricular swelling, severe headache)

Consider treatment failure causes: 1

• Inadequate drug delivery (canal still obstructed with debris)
• Poor adherence to drop administration
• Fungal co-infection (especially if white fuzzy exudate develops)
• Allergic contact dermatitis from topical agents
• Incorrect diagnosis

Special Considerations for High-Risk Patients

If the patient has diabetes or is immunocompromised: 1

• Monitor more carefully for necrotizing otitis externa
• Consider adding systemic antibiotics even for seemingly uncomplicated cases
• Avoid ear canal irrigation—use atraumatic suction instead
• Lower threshold for ENT referral

Patient Education

Instruct the patient to: 1

• Keep the ear dry during treatment (cover with petroleum jelly-coated cotton before showering)
• Avoid inserting cotton swabs or any objects into the ear canal
• Complete the full 7-day course even if symptoms resolve
• Return immediately if tasting the eardrops (indicates tympanic membrane perforation)
• Return if no improvement within 48-72 hours

Common Pitfalls to Avoid

• Prescribing oral antibiotics for uncomplicated cases (occurs inappropriately in 20-40% of patients) 1
• Using aminoglycoside-containing drops when tympanic membrane integrity is unknown 1
• Failing to clean the ear canal before administering drops 1
• Inadequate pain management 1
• Missing fungal infection in patients who fail to respond to antibacterial therapy 1