Antibiotic Ear Drops

Which drops, how to use them, and what to do in the presence of a grommet or perforation

Which drops?

There is often some debate from doctors about which ear drops to use. Although the antibiotics in many of these may theoretically harm the hearing organ (cochlea) if there is a hole in the ear drum (from a perforation or grommet), this is very rare in practice, particularly in the presence of an ear infection- very little of the antibiotic is be able to get through the thickened, inflamed middle ear lining to harm the hearing organ. The highest risk antibiotics are the aminoglycosides (eg gentamicin, neomycin etc.)

ENT-UK, the overseeing body for ENT surgeons in the United Kingdom has published very useful guidance: https://entuk.org/docs/prof/position_papers/position_paper_ear_drops

The key recommendations are:

When treating a patient with a discharging ear, in whom there is a perforation or patent grommet

1. If a topical aminoglycoside is used, this should only be in the presence of obvious infection

2. Topical aminoglycosides should be used for no longer than two weeks

3. The justification for using topical aminoglycosides should be explained to the patient

4. Baseline audiometry should be performed, if possible or practical, before treatment with

topical aminoglycosides

In practice, it is often difficult to obtain an accurate hearing test when patients have infected ears, or in young children, for example. Additionally, one has to usually make a “best guess” regarding the bacteria responsible, as these are often unknown at the first consultation. Pseudomonas is often the culprit, giving a fishy-smelling discharge. I obtain swabs from affected ear(s), and then prescribe ciprofloxacin eye drops to be used in the ear (three drops to the affected ear(s) twice daily for 7 days. These are active against:

Aerobes, gram-positive:

Staphylococcus aureus
Streptococcus pneumoniae

Aerobes, gram-negative:

Escherichia coli
Haemophilus influenzae
Moraxella catarrhalis
Proteus mirabilis
Pseudomonas aeruginosa

Ciprofloxacin is from a family of antibiotics thought to have a very small risk of hearing organ damage, particularly compared to the aminoglycosides. Ciprofloxacin ear drops are now available in the UK: Cetraxal 2mg/ml (0.2%) ear drops 0.25ml unit dose (Aspire Pharma Ltd).

As an alternative, I also prescribe ciprofloxacin eye drops for the ears: Ciloxan (0.3%) to be used off licence in the ear(s), if the ear drops are not available.

I provide an otoscope speculum (the little black disposable funnel on the end of the “ear torch” which doctors use) and ask parents to lie their child on his/her side (with the affected ear uppermost) on an old towel on the sofa while watching TV. The otoscope speculum is then used as a funnel in the ear to help instil the drops. These are left in the ear for 10-15 minutes, before turning over on the towel to allow the drops and ear debris to drain out onto the towel. This is much more easily done well twice a day before and after school/nursery than three times quickly.

Further treatment and advice

I review the swab results which are usually ready after 3-4 days. The bacteria will often be the ones covered by ciprofloxacin, but other drops may be needed, including aminoglycosides. One should bear in mind that the risks of hearing organ toxicity with any of these ear drop types is very low. An untreated infection is likely to be more risky to the hearing.

Please seek medical attention if the discharge persists, or other symptoms develop. While this is very rare, signs of hearing organ damage include noise in the ear (tinnitus), dizziness and hearing loss: please stop the drops if this occurs.

The affected ear(s) should be kept dry for several weeks. Please see the keeping the ears dry section for further information.