What is the correct treatment for severe external otitis (otitis externa)?

From the Guidelines

The correct treatment for severe otitis externa involves a comprehensive approach starting with thorough cleaning and debridement of the ear canal by a healthcare provider, followed by the use of topical antibiotic drops containing fluoroquinolones, such as ciprofloxacin or ofloxacin, combined with steroids to reduce inflammation, applied 3-4 times daily for 7-10 days, as recommended by the clinical practice guideline: acute otitis externa 1. The primary goal of treatment is to reduce morbidity, mortality, and improve quality of life by effectively managing the infection and preventing potential complications. Key considerations in the treatment of severe otitis externa include:

• Thorough cleaning and debridement of the ear canal to remove debris and promote healing
• Use of topical antibiotic drops, such as ciprofloxacin or ofloxacin, combined with steroids to reduce inflammation and prevent further infection
• Pain management with acetaminophen or NSAIDs to reduce discomfort and promote recovery
• Keeping the ear dry during treatment, avoiding swimming and using ear plugs during showers to prevent further irritation and infection
• Follow-up with a healthcare provider within 48-72 hours of starting treatment to assess response to therapy and potential need for alternative treatment, as some patients may not respond to initial treatment due to resistant organisms or fungal infection, as noted in the clinical practice guideline: acute otitis externa executive summary 1. It is essential to note that the treatment approach may vary depending on individual patient factors, such as the presence of underlying medical conditions, such as diabetes or immunocompromised states, which may require special consideration and alternative treatment approaches, as discussed in the clinical practice guideline: acute otitis externa 1.

From the FDA Drug Label

Ciprofloxacin otic solution, 0.2% is a quinolone antimicrobial indicated for the treatment of acute otitis externa due to susceptible isolates of Pseudomonas aeruginosa or Staphylococcus aureus. The contents of one single-dose container (deliverable volume: 0. 25 mL) should be instilled into the affected ear twice daily (approximately 12 hours apart) for 7 days.

The correct treatment for severe otitis externa is not explicitly stated in the provided drug labels. However, for acute otitis externa, the treatment is:

• Ciprofloxacin otic solution, 0.2%: instill 0.25 mL into the affected ear twice daily for 7 days 2.
• Ofloxacin otic solution: instill 0.5 mL (10 drops) into the affected ear once daily for 7 days for patients 13 years and older, and 0.25 mL (5 drops) once daily for 7 days for pediatric patients from 6 months to 13 years old 3. It is essential to note that the severity of otitis externa may require different treatment approaches, and these recommendations may not be directly applicable to severe cases.

From the Research

Treatment for Severe Otitis Externa

• The treatment of acute otitis externa consists of analgesia, cleansing of the external auditory canal, and the application of antiseptic and antimicrobial agents 4.
• Local antibiotic and corticosteroid preparations have been found useful in the treatment of otitis externa, with topical antimicrobial treatments leading to a higher cure rate than placebo, and corticosteroid preparations lessening swelling, erythema, and secretions 4.
• Oral antibiotics are indicated if the infection has spread beyond the ear canal or in patients with poorly controlled diabetes mellitus or immunosuppression 4, 5.
• Topical medications include acetic acid 2%, aminoglycosides, polymyxin B, and quinolones with and without corticosteroids, with no evidence that any one preparation is clinically superior to another 5.
• The choice of treatment is based on factors such as cost, whether the tympanic membrane is intact, and patient adherence 5.
• Duration of topical treatment is usually seven to 10 days 5.
• In severe cases, systemic antibiotics may be necessary, with oral ciprofloxacin being a effective and safe option for the treatment of external bacterial otitis 6.

Prevention and Management

• Avoiding injury to the ear canal and keeping it free of water are key to prevention 5.
• Thorough cleansing of the canal is essential for diagnosis and treatment, but flushing should be avoided 7.
• Acidification with a topical solution of 2 percent acetic acid combined with hydrocortisone for inflammation is effective treatment in most cases and, when used after exposure to moisture, is an excellent prophylactic 7.
• Other prophylactic measures such as drying the ears with a hair dryer and avoiding manipulation of the external auditory canal may help prevent recurrence 7.