# Acute otitis externa - Category: infectious - Review status: reviewed (every claim checked against a document named on this page) - Sources: Egyptian National Drug Formulary - Antimicrobial 2023 · AAO-HNS Clinical Practice Guideline 2014 · Daktacort (miconazole 2% + hydrocortisone 1%) cream SmPC sections 4.1-4.2 (eMC product 1557) · Acute otitis externa - disease-level clinical article (otitis-externa-full.txt) · MSF Essential Drugs 2024 (paracetamol oral monograph) · MSF Essential Drugs 2024 (ibuprofen oral monograph) · Ofloxacin Otic Solution 0.3% - DailyMed prescribing information (Amneal Pharmaceuticals NY LLC) - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary - Antimicrobial 2023 - Daktacort (miconazole 2% + hydrocortisone 1%) cream SmPC sections 4.1-4.2 (eMC product 1557) - Acute otitis externa - disease-level clinical article (otitis-externa-clinical.txt) - Acute otitis externa - disease-level clinical article (otitis-externa-full.txt) - MSF Essential Drugs 2024 (paracetamol oral monograph) - MSF Essential Drugs 2024 (ibuprofen oral monograph) ## Treatment metadata - Ciprofloxacin — ear - Referral & safety-netting (no drug therapy) - Ofloxacin — ear - Hydrocortisone + Miconazole — topical - Paracetamol — 500 mg — oral.solid - Ibuprofen — 400 mg — oral.solid ## Complete treatment card ```text ACUTE OTITIS EXTERNA Sources: Egyptian National Drug Formulary - Antimicrobial 2023 · AAO-HNS Clinical Practice Guideline 2014 · Daktacort (miconazole 2% + hydrocortisone 1%) cream SmPC sections 4.1-4.2 (eMC product 1557) · Acute otitis externa - disease-level clinical article (otitis-externa- full.txt) · MSF Essential Drugs 2024 (paracetamol oral monograph) · MSF Essential Drugs 2024 (ibuprofen oral monograph) · Ofloxacin Otic Solution 0.3% - DailyMed prescribing information (Amneal Pharmaceuticals NY LLC) Review status: REVIEWED against Egyptian National Drug Formulary - Antimicrobial 2023, Daktacort (miconazole 2% + hydrocortisone 1%) cream SmPC sections 4.1-4.2 (eMC product 1557), Acute otitis externa - disease-level clinical article (otitis-externa-clinical.txt), Acute otitis externa - disease-level clinical article (otitis-externa-full.txt), MSF Essential Drugs 2024 (paracetamol oral monograph), MSF Essential Drugs 2024 (ibuprofen oral monograph) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (4) - Itching and ear pain that worsens with pulling on the ear or pressing the tragus are the presenting complaints [ear pain · itching] - The pain is often out of proportion to how the ear canal looks, because the thin skin over the ear canal bone is very sensitive - Ear discharge, a plugged-up feeling, and hearing loss can also occur [ear discharge · hearing loss] - A fever over 101 F (38.3 C) with malaise suggests the infection has spread beyond the ear canal [fever · malaise] SIGNS - what you find (5) - The ear canal looks red and swollen with yellow, white, or gray debris on otoscopy - The eardrum may look red or be hard to see fully because of canal swelling - Fluid visible behind the eardrum suggests otitis media is also present - In severe disease the canal is completely swollen shut, with intense pain, swollen nodes, and fever [fever] - Mild disease shows itching, mild discomfort, and canal swelling, while moderate disease has partial blockage of the canal [itching] TESTS (3) - Routine labs or ear cultures are not needed for a straightforward case - Cultures are reserved for infections that keep coming back or resist treatment, especially in immunocompromised patients - Blood glucose and HIV testing can be considered when symptoms are severe IF NOT THIS - what else fits (9) - In children, otitis media with a ruptured eardrum and drainage is an important item on the differential - If it is unclear whether this or otitis media with perforation is present, treating for both is reasonable - Contact dermatitis of the ear canal is on the differential - Psoriasis of the ear canal is on the differential - A boil (furunculosis) in the ear canal is on the differential - Herpes zoster oticus (Ramsay Hunt syndrome) is on the differential - TMJ syndrome can mimic ear pain and is on the differential - A retained foreign body in the ear canal is on the differential - Cancer of the ear canal is on the differential, particularly in resistant or unusual cases Source StatPearls "Otitis Externa" - disease-level clinical article Status traced to the source above Rx: Ciprofloxacin | Main treatment | Ofloxacin | Analgesia CIPROFLOXACIN 1. CIPROFLOXACIN [1st line] Adult Instill 3-4 drops into affected ear twice daily x 7 days Peds Over 1 year: 3 drops twice daily into affected ear for 7 days (Children >1 year: 3 drops twice daily into affected ear for 7 days) AWaRe WATCH group - carries resistance cost. Egyptian EML 2025. Source Egyptian National Drug Formulary - Antimicrobial 2023 Why Ciprofloxacin ear drops target the bacterial pathogens, commonly Pseudomonas and Staphylococcus species, that cause acute otitis externa; it is favored here because it is non-ototoxic and can be used safely even when the tympanic membrane is perforated. Caution Keep ear canal dry during treatment. Clean debris from ear canal prior to instillation. Ciprofloxacin is safe with a perforated tympanic membrane (non-ototoxic). Egypt CIPRO 0.3% EAR DROPS 10 ML CID 15.00 EGP MAIN TREATMENT - choose one 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Otitis Externa - disease-level clinical article (otitis-externa-full.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Malignant (necrotizing) otitis externa should be suspected in diabetic or immunocompromised patients with OE and fever not responding to treatment - a life- threatening condition needing antipseudomonal antibiotics and urgent recognition. RED FLAG - The indications requiring oral antibiotics or escalation beyond topical therapy are diabetes with increased morbidity, HIV/AIDS, suspected malignant otitis externa, and concomitant acute otitis media. RED FLAG - If tympanic membrane perforation is suspected, ototoxic drops (aminoglycosides such as neomycin/polymyxin B, and alcohol-based preparations) must be avoided; fluoroquinolones are the recommended, non-ototoxic option. RED FLAG - The ENT referral criteria are complete occlusion of the ear canal, no response to treatment within 72 hours, or suspected necrotizing otitis externa. 3. HYDROCORTISONE + MICONAZOLE [2nd line] Adult Apply the cream thinly to the outer ear canal twice daily x 7 days maximum Peds Over 2 years: Apply thinly to the outer canal twice daily, for 7 days at most (Over 2 years: apply thinly to the outer canal twice daily, 7 days at most.) Source Daktacort (miconazole 2% + hydrocortisone 1%) cream SmPC sections 4.1-4.2 (eMC product 1557) Why This combines a topical antifungal, miconazole, with a corticosteroid, hydrocortisone, to treat the fungal or mixed bacterial-fungal component of otitis externa while calming the inflammation and itching of the ear canal. Caution CONTRAINDICATED if tympanic membrane perforation is suspected. Only for otitis externa where a fungal cause is suspected - not for otitis externa generally. The disease source does not treat a topical antifungal as first-line at all: it is reserved for the case where otoscopy or a culture points to fungus. (Otitis Externa - disease-level clinical article, otitis-externa-full.txt). Discontinue if local irritation or sensitization occurs. Avoid prolonged use (>14 days) to prevent fungal superinfection. There is no miconazole-plus-hydrocortisone ear drop licensed for people anywhere - the only one is a veterinary product. Every Egyptian pack behind it is a skin cream, so it goes on the outer canal with a finger or a wick, not instilled as drops. The ciprofloxacin above it is the preparation that actually holds an ear licence. Seven days is the label's ceiling, and the cream is barred from mucous membranes - keep it to the canal skin and no deeper. Egypt does register a proper ear drop of this kind: clioquinol with flumethasone, sold as VIOTIC (23 EGP) and OTOCORT (26 EGP). It is licensed for the ear, which this cream is not. Whether to use it instead is a prescriber's decision - it is not listed here because no dosing label for it could be opened, and no dose is shown here that cannot be cited. Egypt MONICORT CREAM 10 GM PHAROPHARMA 5.25 EGP MYKOTRAL H TOPICAL CREAM 15 GM SIGMA 6.50 EGP MYCOCORT CREAM 15 GM ARAB DRUG COM... 7.00 EGP DERMOZOL CORT CREAM 15 GM PHARCO 19.50 EGP MONICORT CREAM 20 GM PHAROPHARMA 23.50 EGP DAKTACORT CREAM 15 GM MINA PHARM > ... 48.00 EGP MICONAZ-H TOPICAL EMULGEL 20 GM MUP 10.00 EGP OFLOXACIN 4. OFLOXACIN [1st line] Adult 5 drops to the affected ear twice daily x 7 to 10 days Peds 6 months to 13 years: Five drops (0.25 mL, 0.75 mg ofloxacin) into the affected ear once daily for seven days, with an intact tympanic membrane. Not established below six months. (From six months, for otitis externa with an intact eardrum. The ofloxacin otic label's paediatric dose, ages 6 months to 13 years, is five drops (0.25 mL, containing 0.75 mg of ofloxacin) placed in the affected ear once a day for a week. Below six months, safety and efficacy have not been established.) Source Acute otitis externa - disease-level clinical article (otitis-externa-full.txt) Why Topical fluoroquinolone ear drops for uncomplicated acute otitis externa. Caution Pregnancy Category C. The ofloxacin otic label restricts it in pregnancy to the case where the expected benefit is judged to outweigh the possible risk to the fetus. Egypt OTOXIN 3MG/ML EAR DROPS SEDICO 11.00 EGP ANALGESIA - give alongside 5. PARACETAMOL [add-on - not a substitute] Adult 1 g 3 or 4 times daily (maximum 4 g daily) Peds 15 mg/kg/dose [child max 500 mg] (MSF: child under 1 month, 10 mg/kg 3 or 4 times daily (max. 40 mg/kg daily); child 1 month and over, 15 mg/kg 3 or 4 times daily (max. 60 mg/kg daily).) 3kg -> 45 mg/dose 4kg -> 60 mg/dose 5kg -> 75 mg/dose 6kg -> 90 mg/dose 7kg -> 105 mg/dose 8kg -> 120 mg/dose 9kg -> 135 mg/dose 10kg -> 150 mg/dose 11kg -> 165 mg/dose 12kg -> 180 mg/dose 13kg -> 195 mg/dose 14kg -> 210 mg/dose 15kg -> 225 mg/dose 16kg -> 240 mg/dose 17kg -> 255 mg/dose 18kg -> 270 mg/dose 19kg -> 285 mg/dose 20kg -> 300 mg/dose 21kg -> 315 mg/dose 22kg -> 330 mg/dose 23kg -> 345 mg/dose 24kg -> 360 mg/dose 25kg -> 375 mg/dose 26kg -> 390 mg/dose 27kg -> 405 mg/dose 28kg -> 420 mg/dose 29kg -> 435 mg/dose 30kg -> 450 mg/dose 31kg -> 465 mg/dose 32kg -> 480 mg/dose 33kg -> 495 mg/dose 34kg -> 500 mg/dose (capped) 35kg -> 500 mg/dose (capped) 36kg -> 500 mg/dose (capped) 37kg -> 500 mg/dose (capped) 38kg -> 500 mg/dose (capped) 39kg -> 500 mg/dose (capped) 40kg -> 500 mg/dose (capped) 41kg -> 500 mg/dose (capped) 42kg -> 500 mg/dose (capped) 43kg -> 500 mg/dose (capped) 44kg -> 500 mg/dose (capped) 45kg -> 500 mg/dose (capped) 46kg -> 500 mg/dose (capped) 47kg -> 500 mg/dose (capped) 48kg -> 500 mg/dose (capped) 49kg -> 500 mg/dose (capped) 50kg -> 500 mg/dose (capped) Choice Alternatives. The disease article offers acetaminophen or an NSAID for this pain, without ranking them. Paracetamol is named first choice because MSF contraindicates ibuprofen in peptic ulcer, asthma, renal impairment and dehydration, while paracetamol's only stated caution is hepatic impairment - so it is the safer default when the prescriber has not assessed those. Ibuprofen stays on the card. Source MSF Essential Drugs 2024 (paracetamol oral monograph) Why The disease article makes pain control a co-equal mainstay of treatment alongside topical antibiotics; the card carried no analgesic at all, though pain is the dominant symptom. Caution Administer with caution to patients with hepatic impairment. Do not exceed indicated doses, especially in children and older patients - paracetamol intoxications are severe (hepatic cytolysis). Reduce the dose in children with severe acute malnutrition: 10 mg/kg up to 3 times maximum per 24 hours. Paracetamol has no anti-inflammatory properties. Egypt FEBRIMOL 500 MG 20 TAB. PHARCO 3.50 EGP (0.17/unit) CETAMOL 500 MG 20 TABS. MEMPHIS 8.00 EGP (0.40/unit) PARACETAMOL-MUP 500MG B.P. 20 TABS. MUP 13.00 EGP (0.65/unit) CETAL 500 MG 20 TABS. EIPICO 24.00 EGP (1.20/unit) ARKADOLOW 500 MG 30 F.C. TABS. UTOPIA 42.00 EGP (1.40/unit) PARAMOL 500MG 20 TAB. MISR 38.00 EGP (1.90/unit) ADOL 500MG 24 CAPLETS JULPHAR 32.00 EGP AUGICETAMIDE 500 MG 20 SACHETS AUG PHARMA 50.00 EGP FEBRIMOL ORAL DROPS 20 ML PHARCO 4.00 EGP -> ? strength differs, ? different route - not oral solid THERA-LO 3.2G/100ML ORAL SUSP. 100 ML PHAROPHARMA 5.00 EGP -> ? strength differs, ? different route - not oral solid 6. IBUPROFEN [add-on - not a substitute] Adult 200 to 400 mg 3 to 4 times daily (maximum 1,200 mg daily) Peds 5-10 mg/kg/dose [child max 400 mg] (MSF: child over 3 months, 5 to 10 mg/kg 3 to 4 times daily (max. 30 mg/kg daily).) 3kg -> 15-30 mg/dose 4kg -> 20-40 mg/dose 5kg -> 25-50 mg/dose 6kg -> 30-60 mg/dose 7kg -> 35-70 mg/dose 8kg -> 40-80 mg/dose 9kg -> 45-90 mg/dose 10kg -> 50-100 mg/dose 11kg -> 55-110 mg/dose 12kg -> 60-120 mg/dose 13kg -> 65-130 mg/dose 14kg -> 70-140 mg/dose 15kg -> 75-150 mg/dose 16kg -> 80-160 mg/dose 17kg -> 85-170 mg/dose 18kg -> 90-180 mg/dose 19kg -> 95-190 mg/dose 20kg -> 100-200 mg/dose 21kg -> 105-210 mg/dose 22kg -> 110-220 mg/dose 23kg -> 115-230 mg/dose 24kg -> 120-240 mg/dose 25kg -> 125-250 mg/dose 26kg -> 130-260 mg/dose 27kg -> 135-270 mg/dose 28kg -> 140-280 mg/dose 29kg -> 145-290 mg/dose 30kg -> 150-300 mg/dose 31kg -> 155-310 mg/dose 32kg -> 160-320 mg/dose 33kg -> 165-330 mg/dose 34kg -> 170-340 mg/dose 35kg -> 175-350 mg/dose 36kg -> 180-360 mg/dose 37kg -> 185-370 mg/dose 38kg -> 190-380 mg/dose 39kg -> 195-390 mg/dose 40kg -> 200-400 mg/dose 41kg -> 205-400 mg/dose (upper capped) 42kg -> 210-400 mg/dose (upper capped) 43kg -> 215-400 mg/dose (upper capped) 44kg -> 220-400 mg/dose (upper capped) 45kg -> 225-400 mg/dose (upper capped) 46kg -> 230-400 mg/dose (upper capped) 47kg -> 235-400 mg/dose (upper capped) 48kg -> 240-400 mg/dose (upper capped) 49kg -> 245-400 mg/dose (upper capped) 50kg -> 250-400 mg/dose (upper capped) Source MSF Essential Drugs 2024 (ibuprofen oral monograph) Why Named by the disease article as the alternative to acetaminophen for mild to moderate pain in otitis externa. Caution Do not administer to children under 3 months, patients with allergy to NSAID, peptic ulcer, coagulation defects, haemorrhage, surgery with risk of major blood loss, severe renal or hepatic impairment, severe heart failure, severe malnutrition, uncorrected dehydration or hypovolaemia, severe infection. Administer with caution to elderly or asthmatic patients. Do not combine with methotrexate, anticoagulants and other NSAIDs. Avoid in pregnancy; ibuprofen is contraindicated from the beginning of the 6th month - use paracetamol. Egypt DAJUANOFEN 400 MG 20 F.C. TABS. COPAD PHARMA 5.00 EGP (0.25/unit) FLABU 400MG 10 F.C.TAB. DELTA PHARMA 3.75 EGP (0.38/unit) NOVA-PROFEN 400MG 30 F.C. TABLETS SANOFI 12.75 EGP (0.42/unit) IBUPROFEN 400 MG 10 TAB. SEDICO 6.00 EGP (0.60/unit) MAFO 400 MG 30 F.C.TABS EIPICO 42.00 EGP (1.40/unit) BRUFEN 400 MG 30 TABS. KAHIRA > ABBO... 78.00 EGP (2.60/unit) PROFUSOL 400MG 20 S.G CAPS. EUROPEAN EGYP... 31.00 EGP ANALGIPROF 400 MG 25 SACHETS EVA PHARMA 37.50 EGP NOVA-PROFEN 100MG/5ML ORAL SUSP. 100ML SANOFI 2.25 EGP -> ? strength differs, ? different route - not oral solid BRUFEMOL-N SUSP. 60 ML ARAB DRUG COM... 4.50 EGP -> ? strength differs, ? different route - not oral solid Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)