Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

bacterial

1st line – antibacterial otic drops

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ACUTE
|
bacterial
|
initial treatment in otherwise healthy people
1st line – 

antibacterial otic drops

In people who do not have other medical issues such as diabetes, HIV/AIDS, other immunocompromised states, or a history of radiotherapy, and who do not have signs of fungal infection or necrotising otitis externa, initial presumptive treatment is with topical antibacterial ear drops, plus analgesia.[1]

Prior to the use of topical ear drops, the ear canal needs to be cleaned of any debris or wax by dry swabbing or microsuction.[18]

Patients who have severe swelling of the ear canal may have difficulty in using ear drops. A wick should be inserted in the ear canal to allow for drug delivery.

Ototoxic ear drops (those that contain aminoglycosides and alcohol) should be avoided in patients with possible tympanic membrane perforations, including those with a tympanostomy tube.[1][12]

Ciprofloxacin/dexamethasone, ofloxacin, and ciprofloxacin can be used in patients with perforated tympanic membranes.[1][31]

Primary options

ciprofloxacin/dexamethasone otic: (0.3%/0.1%) children ≥6 months of age and adults: 4 drops into the affected ear(s) twice daily for 7-10 days

OR

ofloxacin otic: (0.3%) children ≥6 months of age: 5 drops into the affected ear(s) once daily for 7 days; adults: 10 drops into the affected ear(s) once daily for 7 days

OR

ciprofloxacin otic: (0.2% solution) children and adults: 0.5 mg (0.25 mL single-use container) into the affected ear(s) twice daily for 7 days; (6% suspension) children ≥6 months of age and adults: 12 mg (0.2 mL single-use container) into external ear canal of the affected ear(s) as a single dose

Secondary options

ciprofloxacin/hydrocortisone otic: (0.2%/1%) children ≥1 year of age and adults: 3 drops into the affected ear(s) twice daily for 7-10 days

OR

neomycin/polymyxin B/hydrocortisone otic: children: 3 drops into the affected ear(s) three to four times daily for 7-10 days; adults: 4 drops into the affected ear(s) three to times daily for 7-10 days

Consider – pain management

Back
ACUTE
|
bacterial
|
initial treatment in otherwise healthy people
Consider – 

pain management

Additional treatment recommended for SOME patients in selected patient group

Analgesics increase patient satisfaction and allow faster return to normal activities.

Mild to moderate pain is usually controlled by paracetamol or a non-steroidal anti-inflammatory drug given alone or in combination with an opioid (e.g., paracetamol with codeine or paracetamol with oxycodone).[1] Analgesics should be started at the initial recommended dose and adjusted accordingly.

Codeine is contraindicated in children younger than 12 years, and it is not recommended in adolescents aged 12-18 years who are obese or have conditions such as obstructive sleep apnoea or severe lung disease as it may increase the risk of breathing problems.[61] It is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children aged 12 years and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[62][63]

Primary options

paracetamol: children: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

paracetamol/codeine: children ≥12 years of age: consult specialist for guidance on dose; adults: 15-60 mg orally orally every 4-6 hours

More

OR

oxycodone/paracetamol: adults: 5-10 mg orally (immediate-release) every 4-6 hours when required

More

1st line – topical and systemic antibacterial therapy

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ACUTE
|
bacterial
|
refractory to initial treatment, or with diabetes or with immunodeficiency
1st line – 

topical and systemic antibacterial therapy

Patients with diabetes or those who are immunocompromised benefit from the addition of oral antibiotics.[1] In addition, patients who failed to respond to 48-72 hours of topical treatment, despite a correct diagnosis of diffuse acute otitis externa (AOE) and good adherence with treatment, may also benefit from systemic antibiotics, particularly if any ear canal obstruction cannot be addressed.[1] Culture and sensitivity may help to guide antibiotic therapy in patients refractory to initial treatment. Patients with concurrent middle ear disease, such as acute otitis media or a tympanic membrane perforation, may also require systemic antibiotics.[1]

Both the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA) have issued warnings about serious, disabling, and potentially irreversible adverse effects associated with systemic and inhaled fluoroquinolone antibiotics. These adverse effects include tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[43][46][47]​​ The EMA now recommends that fluoroquinolone antibiotics be restricted for use in serious, life-threatening bacterial infections only.[43] The FDA has also issued certain restrictions.[45] Despite this, a systemic fluoroquinolone is usually required in patients with non-necrotising otitis externa who have comorbidities (diabetes or immunocompromised state), as they are at higher risk for rapid escalation from mild to severe manifestations of AOE or for developing necrotising otitis externa.[1][12][42]​​ Advice should be sought from an infectious diseases specialist to guide selection of antibiotic and decide on whether a fluoroquinolone is warranted here. In these patients, cultures may be taken to assist in the proper choice of oral antibiotics. Oral amoxicillin/clavulanate or amoxicillin are other options to cover Staphylococcus aureus if Pseudomonas aeruginosa is unlikely, or while awaiting results, or if cultures are negative.

Prior to the use of topical ear drops, the ear canal needs to be cleaned of any debris or wax by dry swabbing or microsuction.[18]​ However, irrigation should not be used to remove debris from these patients’ ear canals, as this may predispose the patients to necrotising otitis externa.[1]

Patients who have severe swelling of the ear canal may have difficulty in using ear drops. A wick should be inserted in the ear canal to allow for drug delivery.

Topical ciprofloxacin/dexamethasone, ofloxacin, and ciprofloxacin can be used in patients with perforated tympanic membranes and so are preferred in this situation.[1][31]

Treatment course: a 10-day course is usually sufficient.

Primary options

ciprofloxacin: children: consult specialist for guidance on dose; adults: 500-750 mg orally twice daily

or

amoxicillin: children ≤3 months of age: 30 mg/kg/day orally given in 2 divided doses; children >3 months of age: 20-40 mg/kg/day orally given in 3 divided doses (maximum 500 mg/dose), or 25-45 mg/kg/day orally given in 2 divided doses (maximum 875 mg/dose); adults: 250-500 mg orally three times daily, or 500-875 mg orally twice daily

More

or

amoxicillin/clavulanate: children ≤3 months of age: 30 mg/kg/day orally given in 2 divided doses; children >3 months of age: 20-40 mg/kg/day orally given in 3 divided doses (maximum 500 mg/dose), or 25-45 mg/kg/day orally given in 2 divided doses (maximum 875 mg/dose); adults: 250-500 mg orally three times daily, or 500-875 mg orally twice daily

More

-- AND --

ciprofloxacin/dexamethasone otic: (0.3%/0.1%) children ≥6 months of age and adults: 4 drops into the affected ear(s) twice daily

or

ofloxacin otic: (0.3%) children ≥6 months of age: 5 drops into the affected ear(s) once daily; adults: 10 drops into the affected ear(s) once daily

or

ciprofloxacin otic: (0.2% solution) children and adults: 0.5 mg (0.25 mL single-use container) into the affected ear(s) twice daily

Consider – pain management

Back
ACUTE
|
bacterial
|
refractory to initial treatment, or with diabetes or with immunodeficiency
Consider – 

pain management

Additional treatment recommended for SOME patients in selected patient group

Analgesics increase patient satisfaction and allow faster return to normal activities.

Mild to moderate pain is usually controlled by paracetamol or a non-steroidal anti-inflammatory drug given alone or in combination with an opioid (e.g., paracetamol with codeine or paracetamol with oxycodone).[1] Analgesics should be started at the initial recommended dose and adjusted accordingly.

Codeine is contraindicated in children younger than 12 years, and it is not recommended in adolescents aged 12-18 years who are obese or have conditions such as obstructive sleep apnoea or severe lung disease as it may increase the risk of breathing problems.[61] It is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children aged 12 years and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[62][63]

Primary options

paracetamol: children: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

paracetamol/codeine: children ≥12 years of age: consult specialist for guidance on dose; adults: 15-60 mg orally orally every 4-6 hours

More

OR

oxycodone/paracetamol: adults: 5-10 mg orally (immediate-release) every 4-6 hours when required

More

1st line – topical and systemic antibacterial therapy plus debridement

Back
ACUTE
|
bacterial
|
necrotising
1st line – 

topical and systemic antibacterial therapy plus debridement

Necrotising otitis externa is a medical emergency.[7]​ All patients in this group should have debridement of granulation tissue.

There are no unified guidelines for the management of necrotising otitis externa. Some clinicians advocate starting intravenous antibiotics immediately, while others start a trial of oral ciprofloxacin in patients who are suspected to have necrotising otitis externa not complicated by cranial nerve involvement.[48] Patients who do not respond to oral antibiotics within 24-48 hours should then be started on intravenous antibiotics. The author's usual practice is to try oral ciprofloxacin in early uncomplicated or suspected necrotising otitis externa and assess the patient's response in 24-48 hours.

Both the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA) have issued warnings about serious, disabling, and potentially irreversible adverse effects associated with systemic and inhaled fluoroquinolone antibiotics. These adverse effects include tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[43][46][47]​ The EMA now recommends that fluoroquinolone antibiotics be restricted for use in serious, life-threatening bacterial infections only.[43] The FDA has also issued certain restrictions.[45] Despite this, a systemic fluoroquinolone is required in patients with necrotising otitis externa.

Oral fluoroquinolones are active against Pseudomonas aeruginosa, penetrate the bone well, have excellent oral bioavailability, and have a less significant side effect profile compared with alternatives.[49]

Oral ciprofloxacin has good coverage against Pseudomonas aeruginosa and is very commonly and successfully used in these patients. Patients can be given oral ciprofloxacin for 6-8 weeks.[50]

Topical ciprofloxacin/dexamethasone, ofloxacin, or ciprofloxacin can be used in conjunction with systemic ciprofloxacin and are safe to use in patients with tympanic membrane perforation.[1][31]​ Ototoxic ear drops (those that contain aminoglycosides and alcohol) should be avoided in patients with possible tympanic membrane perforations.[1][12]​​

If patients fail to respond to oral ciprofloxacin within 24-48 hours, they should be started on intravenous antibiotics that have antipseudomonal activity until culture and sensitivity results are obtained.

Primary options

ciprofloxacin: children: consult specialist for guidance on dose; adults: 500-750 mg orally twice daily for 6-8 weeks

-- AND --

ciprofloxacin/dexamethasone otic: (0.3%/0.1%) children ≥6 months of age and adults: 4 drops into the affected ear(s) twice daily for 7-10 days

or

ofloxacin otic: (0.3%) children ≥6 months of age: 5 drops into the affected ear(s) once daily for 7 days; adults: 10 drops into the affected ear(s) once daily for 7 days

or

ciprofloxacin otic: (0.2% solution) children and adults: 0.5 mg (0.25 mL single-use container) into the affected ear(s) twice daily for 7 days; (6% suspension) children ≥6 months of age and adults: 12 mg (0.2 mL single-use container) into external ear canal of the affected ear(s) as a single dose

Consider – hyperbaric oxygen

Back
ACUTE
|
bacterial
|
necrotising
Consider – 

hyperbaric oxygen

Additional treatment recommended for SOME patients in selected patient group

Hyperbaric oxygenation can be used in patients with refractory or recurrent disease, or in patients with extensive skull base or intracranial involvement although, in one systematic review, no clear evidence was found in demonstrating its efficacy when compared to treatment with antibiotics and/or surgery.[51][53][54]

Consider – pain management

Back
ACUTE
|
bacterial
|
necrotising
Consider – 

pain management

Additional treatment recommended for SOME patients in selected patient group

Analgesics increase patient satisfaction and allow faster return to normal activities.

Mild to moderate pain is usually controlled by paracetamol or a non-steroidal anti-inflammatory drug given alone or in combination with an opioid (e.g., paracetamol with codeine or paracetamol with oxycodone).[1] Analgesics should be started at the initial recommended dose and adjusted accordingly.

Codeine is contraindicated in children younger than 12 years, and it is not recommended in adolescents aged 12-18 years who are obese or have conditions such as obstructive sleep apnoea or severe lung disease as it may increase the risk of breathing problems.[61] It is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children aged 12 years and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[62][63]

Primary options

paracetamol: children: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

paracetamol/codeine: children ≥12 years of age: consult specialist for guidance on dose; adults: 15-60 mg orally orally every 4-6 hours

More

OR

oxycodone/paracetamol: adults: 5-10 mg orally (immediate-release) every 4-6 hours when required

More

2nd line – intravenous antibiotic therapy plus debridement

Back
ACUTE
|
bacterial
|
necrotising
2nd line – 

intravenous antibiotic therapy plus debridement

All patients in this group should have debridement of granulation tissue.

Resistance to ciprofloxacin has been reported, but multi-drug resistance is rare.[7]​ If patients fail to respond to oral ciprofloxacin within 24-48 hours, they should be started on intravenous antibiotics that have anti-pseudomonal activity until culture and sensitivity results are obtained. Empirical intravenous antibiotics should be started based on the recommendation of the local infectious disease specialist. There is no standard recommendation, and the literature reports use of a wide range of antibiotics both singularly and in combination, including third- and fourth-generation cephalosporins (ceftazidime, cefepime), semi-synthetic penicillins (ticarcillin, piperacillin), carbapenems (imipenem), aztreonam, and aminoglycosides (amikacin, tobramycin).[51][52]​ One retrospective case series and systematic literature review concluded that ceftazidime monotherapy for 6-7 weeks was effective for treating necrotising otitis externa.[7]​ In the absence of specialist infectious disease advice, the author considers ceftazidime a reasonable first choice, with the others as alternative options. Suggested doses could vary depending on factors such as the patient's renal function and severity of infection. Amikacin and tobramycin have serious potential side effects on renal function and hearing and should be used with caution and only after consultation with a infectious disease specialist.

Primary options

ceftazidime: children: consult specialist for guidance on dose; adults: 1 g intravenously every 8-12 hours, maximum 6 g/day

Secondary options

cefepime: 1-2 g intravenously every 12 hours

OR

ticarcillin/clavulanic acid: children: consult specialist for guidance on dose; adults: 3.2 g intravenously every 6-8 hours, maximum 18-24 g/day

More

OR

piperacillin: children: consult specialist for guidance on dose; adults: 3-4 g intravenously every 4-6 hours, maximum 24 g/day

OR

imipenem/cilastatin: 500-750 mg intravenously every 12 hours

More

OR

aztreonam: 1-2 g intravenously every 8-12 hours

Tertiary options

amikacin: 7.5 mg/kg intravenously every 12 hours; or 5 mg/kg intravenously every 8 hours

OR

tobramycin: 3 mg/kg/day intravenously given in divided doses every 8 hours

Consider – hyperbaric oxygen

Back
ACUTE
|
bacterial
|
necrotising
Consider – 

hyperbaric oxygen

Additional treatment recommended for SOME patients in selected patient group

Hyperbaric oxygenation can be used in patients with refractory or recurrent disease, or in patients with extensive skull base or intracranial involvement although, in one systematic review, no clear evidence was found in demonstrating its efficacy when compared to treatment with antibiotics and/or surgery.[51][53][54]

Consider – pain management

Back
ACUTE
|
bacterial
|
necrotising
Consider – 

pain management

Additional treatment recommended for SOME patients in selected patient group

Analgesics increase patient satisfaction and allow faster return to normal activities.

Mild to moderate pain is usually controlled by paracetamol or a non-steroidal anti-inflammatory drug given alone or in combination with an opioid (e.g., paracetamol with codeine or paracetamol with oxycodone).[1] Analgesics should be started at the initial recommended dose and adjusted accordingly.

Codeine is contraindicated in children younger than 12 years, and it is not recommended in adolescents aged 12-18 years who are obese or have conditions such as obstructive sleep apnoea or severe lung disease as it may increase the risk of breathing problems.[61] It is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children aged 12 years and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[62][63]

Primary options

paracetamol: children: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

paracetamol/codeine: children ≥12 years of age: consult specialist for guidance on dose; adults: 15-60 mg orally orally every 4-6 hours

More

OR

oxycodone/paracetamol: adults: 5-10 mg orally (immediate-release) every 4-6 hours when required

More

fungal

1st line – topical or oral treatment

Back
ACUTE
|
fungal
1st line – 

topical or oral treatment

Frequent cleaning and debridement by medical professionals is necessary. Prior to the use of topical ear drops, the ear canal needs to be cleaned of any debris or wax by dry swabbing or microsuction.[18]

Patients who have severe swelling of the ear canal may have difficulty in using ear drops. A wick should be inserted in the ear canal to allow for drug delivery.

The first line of treatment of fungal otitis externa is still in debate.[3] Acidifying agents such as acetic acid or aluminium acetate can be used.[12][55]​​ Patients who do not respond to treatment with acidifying agents can be started on antifungal topical treatment.​

Oral antifungals may be used if caused by candidal infection.[13][56]​ Further studies are needed to assess the benefit of oral antifungal agents in otomycosis.[56] Dose and duration of treatment for such an indication have not been fully studied. Itraconazole may be used if caused by Aspergillus infection.[16]

Topical antibiotic treatment, which is indicated in bacterial acute otitis externa, is contraindicated in fungal otitis externa because it is ineffective and may lead to further growth of fungi.[1]

In patients with tympanic membrane perforation, alcoholic solvents used to dissolve water-insoluble antifungal agents (e.g., clotrimazole) can also cause a burning or stinging sensation in the ear and may be ototoxic to the cochlea.​[10] To overcome this, a wick saturated with the antifungal can be inserted in the ear canal to prevent the seepage of the irritant into the middle ear. Self-medication of clotrimazole solution with Q-tips has been shown to improve patient satisfaction and reduce recurrence.[58]​

One study evaluating paper patches in tympanic membrane perforation found that closing the perforation with a patch and applying Castellani’s solution topically was safe and effective, and a faster resolution of otomycosis was observed, accompanied by reduced recurrence.[59]

Primary options

acetic acid/hydrocortisone otic: (2%/1%) children ≥3 years of age and adults: 3-5 drops into the affected ear(s) three times daily for 7-10 days

OR

acetic acid otic: (2%) children and adults: 3-5 drops into the affected ear(s) three times daily for 7-10 days

OR

aluminium acetate topical: (8%) children and adults: consult product literature for guidance on dose

Secondary options

clotrimazole topical: (1%) children ≥2 years of age and adults: 3-4 drops into the affected ear(s) three to four times daily for 7-10 days

Tertiary options

fluconazole: children and adults: consult specialist for guidance on dose

OR

itraconazole: children and adults: consult specialist for guidance on dose

Consider – pain management

Back
ACUTE
|
fungal
Consider – 

pain management

Additional treatment recommended for SOME patients in selected patient group

Analgesics increase patient satisfaction and allow faster return to normal activities.

Mild to moderate pain is usually controlled by paracetamol or a non-steroidal anti-inflammatory drug given alone or in combination with an opioid (e.g., paracetamol with codeine or paracetamol with oxycodone).[1] Analgesics should be started at the initial recommended dose and adjusted accordingly.

Codeine is contraindicated in children younger than 12 years, and it is not recommended in adolescents aged 12-18 years who are obese or have conditions such as obstructive sleep apnoea or severe lung disease as it may increase the risk of breathing problems.[61] It is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children aged 12 years and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[62][63]

Primary options

paracetamol: children: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

paracetamol/codeine: children ≥12 years of age: consult specialist for guidance on dose; adults: 15-60 mg orally orally every 4-6 hours

More

OR

oxycodone/paracetamol: adults: 5-10 mg orally (immediate-release) every 4-6 hours when required

More

2nd line – tympanoplasty or myringoplasty

Back
ACUTE
|
fungal
2nd line – 

tympanoplasty or myringoplasty

Typically, tympanic membrane perforation due to fungal otitis externa is smaller in size and may resolve with treatment. However, some cases may require tympanoplasty or myringoplasty to close the perforation.[10]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer