What are the treatment options for acute otitis externa?

From the Guidelines

Treatment of otitis externa primarily involves topical antimicrobial therapy, pain management, and proper ear cleaning, with first-line treatment typically consisting of antibiotic ear drops such as ciprofloxacin 0.3% or ofloxacin 0.3%, administered as 3-4 drops into the affected ear(s) twice daily for 7-10 days 1.

Key Considerations

• The primary goal of treatment is to achieve clinical resolution of otitis externa, with a focus on reducing morbidity, mortality, and improving quality of life.
• Topical antimicrobial therapy is the mainstay of treatment, with antibiotic ear drops being the first-line treatment option.
• Pain management with oral acetaminophen or NSAIDs is often necessary to alleviate symptoms.
• Proper ear cleaning is essential before applying medications, and may involve gentle irrigation with warm saline or hydrogen peroxide solutions, or careful removal of debris by a healthcare provider.

Treatment Options

• Antibiotic ear drops: ciprofloxacin 0.3% or ofloxacin 0.3%, administered as 3-4 drops into the affected ear(s) twice daily for 7-10 days.
• Combination products containing antibiotics and corticosteroids: ciprofloxacin 0.3%/dexamethasone 0.1% may be more effective for cases with significant inflammation.
• Antifungal preparations: clotrimazole 1% solution may be used if fungal infection is suspected.

Special Considerations

• Severe cases with significant ear canal swelling may require an ear wick to facilitate medication delivery.
• Patients should avoid water exposure during treatment and refrain from inserting objects into the ear canal.
• Treatment is typically effective within 48-72 hours, but the full course should be completed to prevent recurrence.
• If symptoms persist beyond 7 days of treatment, patients should seek further medical evaluation as resistant organisms or alternative diagnoses may be present 1.

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. In a randomized, multi-center, evaluator-blinded study of patients with acute otitis externa, patients were treated with either ciprofloxacin otic solution, 0.2% twice daily or neomycin and polymyxin B sulfates and hydrocortisone otic solution (PNH) three times daily for 7 days. Options to treat otitis externa include:

• Ciprofloxacin otic solution, 0.2% twice daily for 7 days 2
• Neomycin and polymyxin B sulfates and hydrocortisone otic solution (PNH) three times daily for 7 days 2 Key points:
• Ciprofloxacin otic solution, 0.2% is effective against susceptible isolates of Pseudomonas aeruginosa or Staphylococcus aureus 2
• Clinical cure was achieved at the end of a 7-day treatment in 70% of patients treated with ciprofloxacin otic solution, 0.2% and 60% of patients treated with neomycin and polymyxin B sulfates and hydrocortisone otic solution (PNH) 2

From the Research

Treatment Options for Otitis Externa

• Topical antibiotics: Studies have shown that topical antibiotics such as ofloxacin otic solution 3 and ciprofloxacin/dexamethasone 4 are effective in treating otitis externa.
• Topical antiseptics: Antiseptics such as acetic acid 5 have been found to be effective in treating otitis externa, and may be used as a prophylactic measure to prevent recurrence.
• Topical steroids: Steroids such as hydrocortisone 5, 4 may be used to reduce inflammation and swelling in the external auditory canal.
• Non-antibiotic treatments: A systematic review and meta-analysis found that antiseptic, steroid, and antibiotic monotherapies are all effective for the management of acute otitis externa, with no significant differences in cure rates between them 6.

Specific Treatment Regimens

• Ofloxacin otic solution: A study found that ofloxacin otic 0.3% solution administered once daily for 7 days was well tolerated and effective in achieving clinical and microbiologic cure of otitis externa 3.
• Ciprofloxacin/dexamethasone: A study found that ciprofloxacin 0.3%/dexamethasone 0.1% otic suspension was clinically and microbiologically superior to neomycin/polymyxin B/hydrocortisone otic suspension in the treatment of mild to severe acute otitis externa 4.
• Acetic acid and hydrocortisone: A study found that acidification with a topical solution of 2 percent acetic acid combined with hydrocortisone for inflammation was effective treatment in most cases of otitis externa 5.