12.

1 Drugs acting on the ear

12.1.1 Otitis externa
Astringent preparations
Acetic acid 2% ♦ Ear Calm® spray

Anti-inflammatory preparations
Betamethasone ♦ Ear drops 0.1%

(Betnesol®,
Vista-methasone®)
Prednisolone sodium ♦ Ear drops 0.5%

phosphate
Ichthammol glycerin BPC ♦ Ear drops
Notes:
1. It is important to exclude an underlying chronic otitis media before treatment is
commenced.
2. Many cases recover after thorough cleansing of the external ear canal by suction, dry
mopping or gentle syringing.
3. The most effective method is to introduce a ribbon gauze dressing soaked with
corticosteroid ear drops or with an astringent such as aluminium acetate solution.
4. Acetic acid 2% solution is antifungal and antibacterial and may be useful for mild otitis
externa. The proprietary name Ear Calm® spray may be obtained over the counter at
pharmacies.
5. Prolonged use of topical corticosteroids should be avoided.
Anti-infective preparations
Clotrimazole (Canesten®) ♦ Ear drop 1%

Gentamicin ♦ Ear drop 0.3%

Ciprofloxacin ♦ Eye drops 0.3% (see note below)

Ceftazidime ♦ Ear drops 5%. Aseptically produced by

SDHCT pharmacy
Notes:
1. Consideration should be given to the fact that pseudomonal resistance to
aminoglycoside antibiotics is growing.
2. Ear swabs for culture should be reserved for treatment failures or chronic cases
(Prodigy advice, see www.prodigy.nhs.uk ). They may be carried out using an urethral
swab.
3. If infection is present a topical anti-infective agent which is not usually used
systemically (e.g. clioquinol) is indicated. It should be used for about a week only, to
prevent fungal overgrowth or resistance.
4. The CSM continue to advise that topical aminoglycoside antibiotics are
contraindicated in those with a tympanic perforation, in view of reports of ototoxicity
(see current BNF).
5. Fungal infections are usually difficult to treat and specialist referral should be
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 considered if this is suspected. Clotrimazole ear drops may be tried first for 4 weeks
and continued for at least 14 days after disappearance of infection (Prodigy advice).
6. Ciprofloxacin and ceftazidime are included for hospital use only. Ceftazidime is
produced aseptically whilst aural use of ciprofloxacin 0.3% is unlicensed.
Anti-infective plus anti-inflammatory combination preparations
Flumethasone with ♦ Ear drop 0.02% / 1%

clioquinol
(Locorten-Vioform®)
Hydrocortisone with ♦ Ear drop 1% / 0.3%

gentamicin
(Gentisone HC®)
Triamcinolone acetonide ♦ Ear Ointment (Tri-Adcortyl Otic®)
♦ Cream
with antibacterial
Notes:
1. Anti-infective and anti-inflammatory combination products may be used for cases
where infection is present with inflammation and eczema. In combination products
containing an aminoglycoside the notes above apply.
2. Tri-adcortyl Otic® ear ointment and cream are included for use in SDHCT ENT
Outpatients. It contains two different aminoglycosides which are linked to growing
pseudomonal resistance. It is not normally recommended (see BNF), but its use may
be justified in certain circumstances.
3. An acute infection may cause severe pain and a systemic antibacterial is required
together with a simple analgesic such as paracetamol.
4. Clioquinol is indicated for mild bacterial or fungal infections, gentamicin is indicated
for bacterial infections.
12.1.2 Otitis media
Notes:
1. Local treatment of acute otitis is ineffective and there is no place for drops containing
an anaesthetic.
2. Many attacks are viral in origin and need only treatment with a simple analgesic such
as paracetamol for pain.
3. Severe bacterial infection should be treated with systemic antibiotics. For prescribing
information refer to Appendix 3, Chapter 5, Management of infection guidance for
primary care.
12.1.3 Removal of ear wax
Sodium bicarbonate ♦ Ear drops 5%

Olive Oil ♦ Oil dispensed in a suitable container

Notes:
1. Wax is a normal bodily secretion and need only be removed if it causes deafness or
interferes with a proper view of the ear drum.
2. Syringing is best avoided in patients with a history of recurring otitis externa, a history
of ear drum perforation, or previous surgery.
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3. If necessary, wax can be softened before syringing with simple remedies such as
sodium bicarbonate ear drops.
4. If the wax is hard and impacted the drops may be used twice daily for a few days
before syringing; otherwise the wax may be softened on the day of syringing.
5. Sodium bicarbonate ear drops and olive oil are considered the standard first line
products for the removal of ear wax. It is available over the counter at a cost less than
that of the current prescription fee.
6. Other proprietary preparations have not been considered for formulary inclusion.
Some contain organic solvents which may cause irritation e.g. Cerumol®.

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