What treatment is recommended for a 14-year-old boy with otitis externa, tympanic membrane (TM) perforation, and otorrhea?

From the Guidelines

For a 14-year-old boy with otitis externa complicated by tympanic membrane perforation and otorrhea, I strongly recommend using topical antibiotic ear drops, specifically ciprofloxacin-dexamethasone otic drops (Ciprodex), 4 drops in the affected ear twice daily for 7-10 days, as this approach has been shown to have superior outcomes with topical therapy compared to systemic antibiotic therapy 1. This combination provides both antibiotic coverage against common pathogens, such as Pseudomonas aeruginosa, and anti-inflammatory effects to reduce swelling and pain. It's crucial to avoid using potentially ototoxic drops like neomycin-containing preparations since the perforated eardrum allows direct access to the middle ear. Before instilling drops, gently clean the ear canal of discharge using a bulb syringe with warm saline or hydrogen peroxide diluted 1:1 with water. The patient should lie with the affected ear upward for 3-5 minutes after application to ensure proper distribution. Some key points to consider in the management of this condition include:

• The importance of cleaning the ear canal before administering the drops to ensure the medication reaches the middle ear space 1.
• The potential for viral coinfection, which may influence the presentation and management of the condition 1.
• The need for further evaluation if symptoms do not improve within 48-72 hours or if fever develops.
• The preference for fluoroquinolones, such as ciprofloxacin, due to their excellent coverage against common pathogens and non-ototoxic nature 1.
• The role of dexamethasone in reducing inflammation and granulation tissue that often accompanies chronic drainage. As stated in the clinical practice guideline on tympanostomy tubes in children, topical antibiotic ear drops are the recommended treatment for uncomplicated acute tympanostomy tube otorrhea, with a strong recommendation based on randomized controlled trials showing a preponderance of benefit over harm 1.

From the FDA Drug Label

The recommended dosage regimen for the treatment of chronic suppurative otitis media with perforated tympanic membranes in patients 12 years and older is: Ten drops (0.5 mL, 1. 5 mg ofloxacin) instilled into the affected ear twice daily for fourteen days. For patients 13 years and older: Ten drops (0.5 mL, 1. 5 mg ofloxacin) instilled into the affected ear once daily for seven days.

For a 14-year-old boy with otitis externa and tympanic membrane (TM) perforation with otorrhea, the recommended treatment is ofloxacin (OTIC).

• The patient should receive ten drops (0.5 mL, 1.5 mg ofloxacin) instilled into the affected ear twice daily for fourteen days 2.
• The solution should be warmed by holding the bottle in the hand for one or two minutes to avoid dizziness that may result from the instillation of a cold solution.
• The patient should lie with the affected ear upward, before instilling the drops, and then the tragus should be pumped 4 times by pushing inward to facilitate penetration into the middle ear.
• This position should be maintained for five minutes.
• Repeat, if necessary, for the opposite ear.

From the Research

Treatment Options for Otitis Externa with TM Perforation and Otorrhea

• For a 14-year-old boy with otitis externa, TM perforation, and otorrhea, topical antimicrobials or antibiotics such as ofloxacin otic solution 0.3% can be used as treatment 3, 4, 5.
• Ofloxacin otic solution 0.3% has been shown to be effective in treating otitis externa in children and adults, with clinical cure rates of >80% in adults and >95% in children 3, 5.
• This treatment is also effective in the treatment of chronic suppurative otitis media in adolescents and adults with perforated tympanic membranes, with a clinical cure rate of 75 to 91% 3.
• The use of ofloxacin otic solution 0.3% is well tolerated, with limited systemic absorption and a low incidence of adverse events, including bitter taste and pruritus 3, 4.

Comparison with Other Treatments

• Ofloxacin otic solution 0.3% has been compared to other treatments, such as neomycin/polymyxin B/hydrocortisone preparations and oral amoxicillin/clavulanic acid, and has been shown to be as effective or more effective in some cases 3, 4, 5.
• The choice of treatment should be based on factors such as tympanic membrane status, adverse effect profiles, adherence issues, and cost 6.

Safety and Efficacy

• Ofloxacin otic solution 0.3% has been shown to be safe and effective in treating otitis externa in children and adults, with no significant differences in clinical or microbiological cure rates compared to other treatments 3, 5.
• The treatment has also been shown to have a low incidence of adverse events, including ototoxicity, which is a significant advantage over other treatments 3, 4.