What is the recommended treatment for an adult with an ear infection?

Treatment of Ear Infections in Adults

For adults with ear infections, topical antibiotic drops (fluoroquinolones like ofloxacin or ciprofloxacin, or aminoglycoside combinations) are the definitive first-line treatment for otitis externa, while systemic antibiotics like amoxicillin-clavulanate are reserved exclusively for acute otitis media or complicated cases with extension beyond the ear canal. 1, 2

Distinguish the Type of Ear Infection First

The critical first step is determining whether you're dealing with otitis externa (outer ear canal infection) or acute otitis media (middle ear infection), as treatment differs fundamentally. 1

Otitis externa is by far the most common ear infection in adults, affecting approximately 10% of people during their lifetime. 1 Key diagnostic features include:

• Ear pain, itching, discharge, and canal swelling/redness, often following swimming or ear trauma 1
• Tenderness when moving the tragus or pinna strongly suggests otitis externa 1, 3
• Pain is typically the predominant symptom 3

Acute otitis media in adults is less common and presents differently:

• Ear pain with systemic symptoms (fever, malaise) 4
• No tenderness with tragus/pinna manipulation 1
• Requires visualization of middle ear effusion and tympanic membrane inflammation 4

Treatment Algorithm for Uncomplicated Otitis Externa

Step 1: Perform Aural Toilet Before Any Treatment

Before administering drops, the ear canal must be cleared of debris, cerumen, and inflammatory material through gentle suction, dry mopping, or irrigation with body-temperature water, saline, or hydrogen peroxide. 1, 2 This is non-negotiable—medication cannot penetrate through debris to reach infected tissues. 1, 2

Critical exception: In diabetic or immunocompromised patients, avoid irrigation entirely and use only atraumatic suctioning under microscopic guidance, as irrigation can trigger life-threatening necrotizing otitis externa. 2, 5

Step 2: Select Appropriate Topical Antibiotic

If tympanic membrane is intact or you can visualize it clearly:

• Any FDA-approved topical preparation is acceptable 1, 2
• Options include: ofloxacin 0.3%, ciprofloxacin 0.2%, neomycin/polymyxin B/hydrocortisone, or polymyxin B/hydrocortisone 1, 2
• All achieve 65-90% clinical cure rates within 7-10 days with no consistent superiority of one agent over another 2, 3

If tympanic membrane integrity is uncertain, compromised, or patient has tympanostomy tubes:

• Use only non-ototoxic fluoroquinolone preparations: ofloxacin 0.3% or ciprofloxacin 0.2% 1, 2
• Never use aminoglycoside-containing drops (neomycin) as they are ototoxic 2

If patient has history of eczema, contact dermatitis, or chronic otitis externa:

• Avoid neomycin-containing preparations entirely, as neomycin causes contact sensitivity in 13-30% of patients with chronic otitis externa 2
• Use fluoroquinolone-only drops (ofloxacin or ciprofloxacin) 2

Step 3: Ensure Proper Drop Administration

Topical therapy is superior to oral antibiotics because it delivers 100-1000 times higher antibiotic concentrations directly at the infection site. 1, 5 However, only 40% of patients self-administer drops correctly. 2

Proper technique:

• Warm the bottle in hands for 1-2 minutes to prevent dizziness 2
• Have someone else administer drops if possible (significantly improves adherence) 2
• Lie with affected ear upward 2
• Fill the ear canal completely with drops 2
• Maintain position for 3-5 minutes (use a timer) 2
• Apply gentle to-and-fro movement of pinna or press tragus in/out to eliminate trapped air 2

Treatment duration: Minimum 7 days even if symptoms resolve earlier; continue up to 14 days maximum if symptoms persist. 2

Step 4: Provide Adequate Pain Management

Pain assessment and appropriate analgesics are essential, as otitis externa pain can be severe. 2, 5

• Mild-to-moderate pain: Acetaminophen or NSAIDs 1, 2
• Severe pain: Short-term opioids for initial 48-72 hours 2
• Pain typically improves within 48-72 hours of starting topical therapy 1, 2, 5

When Systemic Antibiotics ARE Indicated

Oral antibiotics should NOT be prescribed for uncomplicated otitis externa. 1, 2, 5 This is a critical pitfall—approximately 20-40% of patients inappropriately receive oral antibiotics, which increases antibiotic resistance without clinical benefit. 2

Reserve systemic antibiotics for:

1. Extension of infection beyond the ear canal (periauricular cellulitis, swelling outside the ear) 1, 2, 5
2. Confirmed acute otitis media (middle ear infection) 1
3. Diabetes mellitus or immunocompromised state (higher risk for necrotizing otitis externa) 1, 2, 5
4. Topical therapy cannot reach infected area (severe canal edema despite wick placement) 2, 5

When systemic antibiotics are needed:

• For otitis externa with extension: Fluoroquinolones (ciprofloxacin oral) for Pseudomonas and Staphylococcus coverage 2, 5
• For acute otitis media: Amoxicillin-clavulanate 1.75 g amoxicillin/250 mg clavulanate per day for mild-moderate disease 1, 6

High-Risk Patients Requiring Modified Management

Diabetic or immunocompromised patients require heightened vigilance and modified approach: 1, 2, 5

• Never irrigate the ear canal—use only atraumatic suctioning under microscopic guidance 2, 5
• Monitor carefully for necrotizing otitis externa (life-threatening condition) 1, 2, 5
• Consider adding systemic fluoroquinolones even for seemingly uncomplicated cases 2, 5
• Higher susceptibility to fungal infections (otomycosis) 2

Reassessment and Treatment Failure

Reassess within 48-72 hours if no improvement occurs. 1, 2, 5

Common causes of treatment failure:

• Inadequate drug delivery due to canal obstruction (debris not removed) 2, 5
• Poor adherence to drop administration technique 2, 5
• Allergic contact dermatitis from topical agents (especially neomycin or hydrocortisone) 2, 5
• Fungal co-infection (otomycosis)—suspect if white fuzzy exudate with pruritus 2
• Incorrect diagnosis 2, 5

If treatment fails: Switch to fluoroquinolone-only drops, consider fungal infection requiring antifungal therapy, or refer to otolaryngology if symptoms persist beyond 7 days. 1, 2

Critical Pitfalls to Avoid

• Prescribing oral antibiotics for uncomplicated otitis externa (occurs in 20-40% of cases inappropriately) 2
• Using ototoxic preparations when tympanic membrane integrity is compromised 1, 2
• Failing to remove debris before administering drops 1, 2
• Inadequate pain management 2, 5
• Missing necrotizing otitis externa in diabetic/immunocompromised patients (life-threatening) 1, 2
• Irrigating ear canals in diabetic patients (can trigger necrotizing otitis externa) 2, 5
• Prescribing neomycin to patients with eczema or chronic otitis externa (high sensitization risk) 2

Patient Education Points

• Keep ear dry during treatment; use petroleum jelly-coated cotton before showering 2
• Avoid inserting cotton swabs or any objects into ear canal 2
• Complete full 7-day course even if symptoms resolve early 2
• Return if symptoms don't improve within 48-72 hours 1, 2
• If you taste the eardrops, notify your doctor immediately—this indicates tympanic membrane perforation 2