Which ear drops are safe to use in ears with tympanostomy tubes?

Safe Ear Drops for Tympanostomy Tubes

Quinolone antibiotic ear drops—specifically ofloxacin or ciprofloxacin (with or without dexamethasone)—are the only ear drops that should be used in ears with tympanostomy tubes. 1, 2, 3

Recommended Ear Drops

First-Line Agents (Non-Ototoxic)

• Ofloxacin (Floxin Otic): The safest option for ears with tubes 2, 3, 4

  • Dosing for children 1-12 years with tubes: 5 drops twice daily for 10 days 4
  • Achieves high concentrations at infection site (389-2,850 mcg/g in otorrhea) with minimal systemic absorption 4

• Ciprofloxacin-dexamethasone (Ciprodex): Also safe and effective 2, 3

  • The ciprofloxacin component is non-ototoxic 2
  • Note: Dexamethasone may slightly delay tympanic membrane healing if perforation present, but this is generally not clinically significant 2

Why Quinolones Are Superior

• Provide 1000-fold higher drug concentration at the infection site compared to oral antibiotics 1, 3
• Clinical cure rates of 77-96% versus only 30-67% for oral antibiotics 3
• Cover the most common pathogens: Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae 4

Absolutely Contraindicated Ear Drops

Aminoglycoside-Containing Preparations (NEVER USE)

• Neomycin-containing drops (e.g., Cortisporin): Highly ototoxic when exposed to middle ear 2, 5

  • Repeated use (≥2 prescriptions) significantly increases risk of sensorineural hearing loss (HR 1.45,95% CI 1.05-2.01) 6
  • Case reports document severe deafness and vertigo after use with tubes 7
  • Despite being contraindicated, neomycin drops were still prescribed to 15% of children with tubes in recent studies 5

• Gentamicin-containing drops: Also ototoxic and should be avoided 2, 8

Proper Administration Technique

Critical Steps for Effectiveness

1. Clean the ear canal first of any debris or discharge using cotton-tipped swabs with hydrogen peroxide or gentle suction 1, 3

   • Medication cannot reach the middle ear if the tube is blocked 1

2. Warm the bottle in your hand for 1-2 minutes to prevent dizziness 4

3. Position properly: Child lies with affected ear upward 4

4. "Pump" the tragus 4 times after instilling drops to facilitate penetration through the tube into the middle ear 1, 4

5. Maintain position for 5 minutes after administration 4

Treatment Duration and Precautions

• Limit treatment to 10 days maximum to avoid fungal external otitis (otomycosis) 2, 3, 9
• Avoid water entry during active otorrhea—use cotton with Vaseline to cover ear opening during bathing 3
• No routine prophylactic ear drops after tube placement 1

When Topical Drops Are Not Enough

Add Oral Antibiotics If:

• Cellulitis of the pinna or adjacent skin develops 1, 3
• Concurrent bacterial infection elsewhere (sinusitis, pneumonia, strep throat) 1, 3
• Signs of severe infection: high fever, severe pain, toxic appearance 1, 3
• Otorrhea persists or worsens after 7 days of topical therapy 1, 3
• Child is immunocompromised 1, 3

Common Pitfalls to Avoid

1. Using neomycin drops "because they've always worked": This practice exposes children to unnecessary ototoxicity risk when safer alternatives exist 5, 6

2. Not cleaning the ear canal before drops: Debris blocks medication delivery to the middle ear 1, 3

3. Forgetting to pump the tragus: This step is essential for drops to penetrate through the tube 1, 4

4. Prolonged courses beyond 10 days: Increases risk of fungal superinfection 2, 3

5. Prescribing oral antibiotics as first-line: Topical therapy is superior for uncomplicated tube otorrhea 1, 3