What is the treatment for severe external otitis (otitis externa)?

From the Guidelines

Severe otitis externa requires prompt medical treatment with thorough cleaning of the ear canal by a healthcare provider, followed by application of topical antibiotic drops containing fluoroquinolones (such as ciprofloxacin or ofloxacin) combined with steroids, typically administered 3-4 drops, 3-4 times daily for 7-10 days. The treatment approach should prioritize minimizing morbidity, mortality, and improving quality of life. According to the clinical practice guideline: acute otitis externa 1, the primary outcome considered is clinical resolution of acute otitis externa.

Key Considerations

• For very severe cases, an ear wick may be inserted to facilitate medication delivery deeper into the swollen canal.
• Oral antibiotics like ciprofloxacin (500mg twice daily) or amoxicillin-clavulanate (875/125mg twice daily) for 7-10 days may be necessary if the infection has spread beyond the ear canal.
• Pain management with acetaminophen or ibuprofen is important.
• During treatment, keep the ear dry by avoiding swimming and using earplugs during showers.
• Severe otitis externa requires medical attention because the infection can potentially spread to surrounding tissues (malignant otitis externa), especially in diabetic or immunocompromised patients.
• Complete the full course of prescribed medications even if symptoms improve quickly to prevent recurrence and antibiotic resistance.

Patient Education

• Patients should be advised to avoid scratching or touching the ear and not insert anything into the ear canal, including cotton-tipped swabs 1.
• Cover the opening of the ear canal with an earplug or cotton (with petroleum jelly) prior to showering or hair washing to minimize water entry.
• Check with the doctor regarding swimming or other water activities that may take place during, or soon after, the infection.

Special Considerations

• Patients with diabetes, an immunocompromised state, or both require special consideration because they are susceptible to otomycosis and necrotizing otitis externa, which may present similar to acute otitis externa but require different management 1.
• The ear canal should be cleared of inflammatory debris, obstructing cerumen, or any foreign object, and aural toilet may be performed by the clinician with a gentle lavage using body-temperature water, saline solution, or hydrogen peroxide 1.

The most recent and highest quality study 1 supports the use of topical antibiotic drops as the primary treatment for acute otitis externa, with oral antibiotics reserved for cases where the infection has spread beyond the ear canal or in patients with weakened immune systems.

From the FDA Drug Label

Ciprofloxacin otic solution, 0.2% is a quinolone antimicrobial indicated for the treatment of acute otitis externa due to susceptible isolates of Pseudomonas aeruginosa or Staphylococcus aureus. The contents of one single-dose container (deliverable volume: 0. 25 mL) should be instilled into the affected ear twice daily (approximately 12 hours apart) for 7 days.

The treatment for severe otitis externa is not explicitly stated in the provided drug labels. However, for acute otitis externa, the recommended treatment is:

• Ciprofloxacin otic solution, 0.2%: instill 0.25 mL into the affected ear twice daily for 7 days 2.
• Ofloxacin otic solution: instill 0.5 mL into the affected ear once daily for 7 days for patients 13 years and older, and 0.25 mL once daily for 7 days for pediatric patients from 6 months to 13 years old 3. It is essential to note that the provided information does not directly address severe otitis externa, and the treatment may vary depending on the severity and specific circumstances of the condition.

From the Research

Treatment Options for Severe Otitis Externa

• The treatment of severe otitis externa typically involves cleaning the canal thoroughly and instilling ototopical broad-spectrum antibiotics 4.
• Acidification with a topical solution of 2 percent acetic acid combined with hydrocortisone for inflammation is also an effective treatment in most cases 5.
• Topical non-antibiotic treatments, such as antiseptics and steroids, have been shown to be as effective as topical antibiotic treatment for the treatment of acute otitis externa 6.
• Ciprofloxacin otic 0.2% antibiotic ear solution has been found to be effective in the treatment of acute otitis externa, with high in vitro activity against Pseudomonas aeruginosa 7, 8.

Key Considerations

• Thorough cleansing of the canal is essential for diagnosis and treatment, but flushing should be avoided 5.
• Excessive moisture and trauma can impair the canal's natural defenses and precipitate otitis externa, so avoidance of these factors is crucial in prevention 5.
• The use of topical antibiotics, antiseptics, and steroids should be considered on a case-by-case basis, taking into account the severity of the infection and the patient's individual needs 4, 5, 6, 7, 8.

Potential Therapies

• Ciprofloxacin 0.2% solution has been shown to be statistically equivalent to reference products, such as polymyxin B, neomycin sulfate, and hydrocortisone, in terms of cure rate and microbiological eradication 7.
• A combination of oxytetracycline, polymyxin B, and hydrocortisone has also been used to treat otitis externa, but ciprofloxacin may be a more effective agent in the local therapy of otitis externa 8.