What is the diagnosis and recommended management for a patient with three days of ear pain and otorrhea?

Diagnosis: Acute Otitis Externa with Otorrhea

This patient has acute otitis externa (AOE), and the definitive first-line treatment is topical antibiotic ear drops—specifically a fluoroquinolone preparation such as ofloxacin 0.3% or ciprofloxacin 0.2%—combined with appropriate pain management. 1, 2

Confirming the Diagnosis

The three-day history of ear pain with drainage strongly suggests AOE rather than acute otitis media (AOM). Key diagnostic steps include:

• Perform the tragus tenderness test by pressing on the tragus or pulling the pinna—positive tenderness is pathognomonic for AOE and distinguishes it from AOM 1, 2, 3
• Examine the ear canal for diffuse edema, erythema, debris, or purulent material, which are hallmarks of AOE 1, 2
• Assess tympanic membrane integrity through otoscopy—if a perforation or tympanostomy tube is present, this mandates non-ototoxic topical therapy 1, 2, 4
• Rule out extension beyond the canal by checking for periauricular swelling, cellulitis, or regional lymphadenopathy, which would require systemic antibiotics 1, 2

Essential Pre-Treatment Step: Aural Toilet

Before administering any drops, the ear canal must be cleared of debris, cerumen, and inflammatory material to ensure medication reaches infected tissue. 1, 2, 5

• Use gentle suction, dry mopping, or irrigation with body-temperature water, saline, or hydrogen peroxide 2, 5
• Critical caveat: If the patient has diabetes or is immunocompromised, use only atraumatic suction under microscopic guidance—never irrigate, as this can trigger necrotizing otitis externa 2, 5
• If severe canal edema prevents drop entry or the tympanic membrane cannot be visualized, place a compressed cellulose wick to facilitate drug delivery 2, 5

First-Line Topical Antibiotic Selection

Topical antibiotics achieve 65–90% clinical cure rates within 7–10 days and deliver drug concentrations 100–1000 times higher than oral antibiotics. 2, 5

When Tympanic Membrane Integrity Is Uncertain or Compromised

• Use only non-ototoxic fluoroquinolone preparations: ofloxacin 0.3% or ciprofloxacin 0.2% (with or without dexamethasone) 1, 2, 5, 4
• Avoid aminoglycoside-containing drops (e.g., neomycin/polymyxin B) due to ototoxicity risk 1, 2, 5

When Tympanic Membrane Is Intact

• Any FDA-approved topical preparation is acceptable, including fluoroquinolones or aminoglycoside/polymyxin B/hydrocortisone combinations 2, 5
• However, avoid neomycin-containing preparations if the patient has a history of eczema, contact dermatitis, or chronic/recurrent otitis externa, as neomycin causes contact sensitivity in 13–30% of such patients 2, 5

Dosing and Administration

• Ciprofloxacin 0.2%/dexamethasone 0.1% otic suspension: 4 drops (0.14 mL) into the affected ear twice daily for 7 days 4
• Ofloxacin 0.3% otic solution: typically 5–10 drops twice daily for 7 days 2, 5
• Warm the bottle in hands for 1–2 minutes to prevent dizziness 2, 5, 4
• Have the patient lie with the affected ear upward, instill drops to fill the canal, and maintain this position for 3–5 minutes (use a timer) 2, 5, 4
• Apply gentle to-and-fro movement of the pinna or press the tragus in/out to eliminate trapped air 2, 5
• Complete the full 7-day course even if symptoms resolve early to prevent relapse 2, 5

Pain Management

Pain assessment and appropriate analgesia are essential, as AOE pain can be severe. 1, 2

• Mild-to-moderate pain: acetaminophen 650–1000 mg every 6 hours or ibuprofen 400–600 mg every 6 hours 2
• Severe pain: short-term opioid-containing analgesics (e.g., acetaminophen/oxycodone or ibuprofen/hydrocodone) for the initial 48–72 hours 2
• Pain typically improves within 48–72 hours of starting topical therapy 1, 2, 5
• Do not use topical anesthetic drops (e.g., benzocaine)—they are not FDA-approved for active infections and may mask treatment failure 2, 5

When Systemic Antibiotics Are Indicated

Oral antibiotics should NOT be prescribed for uncomplicated AOE. 1, 2, 5 They are reserved for:

• Extension of infection beyond the ear canal (periauricular cellulitis or swelling) 1, 2, 5
• Diabetes mellitus or immunocompromised state 1, 2, 5
• Severe canal edema preventing adequate topical delivery despite wick placement 2, 5
• Failure to improve after 48–72 hours of appropriate topical therapy 2, 5

When systemic antibiotics are indicated, use fluoroquinolones (e.g., ciprofloxacin 500 mg twice daily) to cover Pseudomonas aeruginosa and Staphylococcus aureus, which cause ~98% of AOE cases. 2, 5

Reassessment and Treatment Failure

Reassess the patient within 48–72 hours if no improvement occurs. 1, 2, 5, 4

Common causes of treatment failure include:

• Inadequate drug delivery due to canal obstruction or poor adherence to the drop regimen 2, 5
• Allergic contact dermatitis from topical agents, particularly neomycin or hydrocortisone 2, 5
• Fungal co-infection (otomycosis), especially in diabetic patients or after prolonged antibiotic use—presents as white fuzzy exudate with pruritus 2, 5, 4
• Incorrect diagnosis—consider chronic suppurative otitis media, necrotizing otitis externa, or dermatologic disorders 2, 5

If otorrhea persists after a full course of therapy or recurs within 6 months, further evaluation is needed to exclude cholesteatoma, foreign body, or tumor. 4

Special Populations: High-Risk Patients

Patients with diabetes or immunocompromised status require heightened vigilance for necrotizing otitis externa. 1, 2, 5

• Monitor carefully for persistent severe pain, granulation tissue, or cranial nerve involvement 2, 5
• Avoid ear canal irrigation—use only atraumatic suction under microscopic guidance 2, 5
• Consider adding systemic antibiotics even for seemingly uncomplicated cases 2, 5
• Higher susceptibility to fungal infections (otomycosis) 2, 5

Patient Education and Activity Restrictions

• Keep the ear dry during treatment—cover the canal with an earplug or petroleum jelly-coated cotton before showering 2, 5
• Avoid swimming and water exposure until infection resolves 2, 5
• Do not insert cotton swabs or any objects into the ear canal 2, 5
• If you taste the eardrops, inform your doctor immediately—this indicates a tympanic membrane perforation 2, 5
• Return for reassessment if symptoms don't improve within 48–72 hours or persist beyond 2 weeks 2, 5

Critical Pitfalls to Avoid

• Prescribing oral antibiotics for uncomplicated AOE (occurs inappropriately in 20–40% of cases) 2, 5
• Using ototoxic preparations when tympanic membrane integrity is compromised 1, 2, 5
• Skipping aural toilet before drop administration—medication cannot penetrate debris 2, 5
• Inadequate pain management 2
• Irrigating the ear canal in diabetic or immunocompromised patients 2, 5
• Missing fungal infections, especially in high-risk patients 2, 5
• Prescribing neomycin-containing drops to patients with eczema or contact dermatitis history 2, 5

Alternative Diagnosis: Acute Otitis Media with Perforation

If otoscopy reveals a bulging tympanic membrane or middle ear effusion rather than canal inflammation, and tragus tenderness is absent, the diagnosis is AOM rather than AOE. 1, 3, 6, 7

• AOM with spontaneous perforation presents with otorrhea but without the intense tragus/pinna tenderness seen in AOE 3, 8, 6
• Treatment for AOM with perforation includes topical fluoroquinolone drops (ofloxacin or ciprofloxacin) plus consideration of oral antibiotics (high-dose amoxicillin 80–90 mg/kg/day or amoxicillin-clavulanate if recent amoxicillin use) 1, 7
• The most common pathogens in AOM with perforation are Haemophilus influenzae (35.8%) and Staphylococcus aureus (26.4%) 9