What are the preferred ear drops for otitis media in children with tympanostomy (ear) tubes?

From the Guidelines

For children with otitis media who have ear tubes, the preferred treatment is typically antibiotic ear drops, such as ciprofloxacin-dexamethasone (Ciprodex) or ofloxacin (Floxin), rather than oral antibiotics, as recommended by the most recent clinical practice guideline update 1. The usual dosage is 4 drops in the affected ear twice daily for up to 10 days, as suggested by previous guidelines 1. For administration, have the child lie with the affected ear facing up, instill the drops, and maintain this position for 1-2 minutes to allow the medication to penetrate the tube. Gently press on the tragus (the small projection in front of the ear canal) a few times to help the drops move through the tube, as advised in the guidelines 1. These topical antibiotics are preferred because they deliver medication directly to the infection site, avoiding systemic side effects of oral antibiotics, and the added steroid component in Ciprodex helps reduce inflammation and ear pain. Some key points to consider when treating children with otitis media who have ear tubes include:

• The importance of cleaning the ear canal of any debris or discharge before administering the drops, to ensure effective delivery of the medication to the middle ear space 1
• The need to prevent water entry into the ear canal during periods of active infection, to reduce the risk of further complications 1
• The potential for biofilm formation, tube obstruction, or other complications if drainage persists beyond 7-10 days of treatment or recurs frequently, which may require reevaluation by a healthcare provider 1
• The recommendation to limit topical therapy to a single course of no more than 10 days, to minimize the risk of inducing fungal external otitis or other adverse effects 1.

From the FDA Drug Label

The recommended dosage regimen for the treatment of acute otitis media in pediatric patients (from 1 to 12 years old) with tympanostomy tubes is: Five drops (0.25 mL, 0. 75 mg ofloxacin) instilled into the affected ear twice daily for ten days. 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, and then the drops should be instilled The tragus should then be pumped 4 times by pushing inward to facilitate penetration of the drops into the middle ear.

The preferred drops for otitis media in kids with tubes are ofloxacin (OTIC), with a dosage of five drops (0.25 mL, 0.75 mg ofloxacin) instilled into the affected ear twice daily for ten days 2.

• Key points:
  • Warm the solution before instillation
  • Instill drops with the affected ear upward
  • Pump the tragus 4 times to facilitate penetration into the middle ear
  • Maintain the position for five minutes after instillation 2.

From the Research

Preferred Drops for Otitis Media in Kids with Tubes

• The preferred drops for otitis media in kids with tubes are topical fluoroquinolone agents, such as ofloxacin or ciprofloxacin, with or without a corticosteroid 3, 4, 5.
• These agents have been shown to be effective in treating acute otitis media with otorrhea through tympanostomy tubes, with a shorter median time to cessation of otorrhea and more clinical cures compared to oral antibiotics 4.
• Topical ciprofloxacin/dexamethasone otic suspension has been found to be superior to ofloxacin otic solution in the treatment of granulation tissue in children with acute otitis media with otorrhea through tympanostomy tubes 6.
• The use of topical fluoroquinolone agents is recommended due to their effectiveness, safety, and reduced risk of ototoxicity and antibiotic resistance 3, 5.

Comparison of Topical Agents

• A study comparing topical ciprofloxacin/dexamethasone otic suspension to oral amoxicillin/clavulanic acid suspension found that the topical agent was superior in terms of clinical cures and cessation of otorrhea 4.
• Another study comparing topical ciprofloxacin/dexamethasone otic suspension to ofloxacin otic solution found that the ciprofloxacin/dexamethasone combination was more effective in reducing granulation tissue 6.

Treatment Considerations

• The treatment of acute otitis media in children with tympanostomy tubes should take into account the risk of antibiotic resistance and ototoxicity 5.
• Topical fluoroquinolone agents, with or without a corticosteroid, are considered the treatment of choice for acute otitis media with tympanostomy tubes due to their effectiveness and safety profile 5.