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Otitis Externa: A Meta-Analysis Comparing Antibiotic And Non-Antibiotic Therapy

Otitis Externa: A Meta-Analysis Comparing Antibiotic And Non-Antibiotic Therapy

Otitis externa, also known as swimmer’s ear, is an inflammatory condition affecting the outer ear canal. This canal extends from the external ear to the eardrum. The inflammation characteristic of otitis externa can be triggered by various factors, including exposure to water, trauma to the ear canal, or the use of certain objects like earplugs or hearing aids.

The symptoms of otitis externa often include itching, discharge, and pain. It is common for individuals with this condition to experience discomfort exacerbated by movement of the ear or when pressure is applied to the tragus, the small pointed cartilage near the ear canal opening.

While otitis externa can have different causes, bacterial infection is a predominant factor in many cases. The most frequently implicated bacteria are Pseudomonas aeruginosa and Staphylococcus aureus. Antibiotics, often in the form of topical eardrops, are commonly prescribed to combat bacterial infection and alleviate symptoms.

Proper hygiene, such as keeping the ears dry, avoiding the insertion of foreign objects into the ear canal, and promptly treating any skin conditions, can contribute to the prevention of otitis externa. However, if symptoms persist or worsen, it’s crucial to seek medical attention for an accurate diagnosis and appropriate treatment.

The Study 

This systematic review and meta-analysis of randomized controlled trials seek to evaluate the efficacy of non-antibiotic topical treatments in comparison to topical antibiotic treatment for managing acute otitis externa.

This endeavor is not only geared toward contributing to the scientific understanding of treatment efficacy but also holds practical implications for clinical decision-making. As the medical landscape continues to evolve, the need for evidence-based guidance becomes increasingly paramount. 

Through synthesizing and analyzing the findings of diverse trials, this systematic review seeks to provide a comprehensive and up-to-date perspective on the effectiveness of non-antibiotic topical treatments. Ultimately, the goal is to contribute valuable insights that can inform clinicians, researchers, and healthcare practitioners in making informed choices for the optimal management of acute otitis externa.


Systematic electronic searches were conducted in the Cochrane Library, including, MEDLINE, EMBASE, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and Web of Science. 

No publication limits were imposed, and search strategies were subject to peer review by an experienced information specialist librarian. Grey literature searches identified additional studies from reference lists, Google, and Google Scholar. Two independent reviewers assessed titles, abstracts, and full manuscripts using Rayyan software ( Exclusions comprised non-English languages and articles failing to meet PICO criteria.

Two independent authors extracted data from eligible studies using a form adapted from the Cochrane template. Recorded in tables for narrative review were data on the setting, population (sample size, age, gender, inclusion/exclusion criteria), interventions, and outcome measures.

The objective was to identify randomized clinical trials that assess the efficacy of topical antibiotics and non-antibiotic agents in treating acute otitis externa in both adults and children. Non-antibiotic treatments for comparison included antiseptics, steroids, non-pharmaceuticals, and astringents.

The inclusion criteria comprised randomized controlled trials (RCTs) investigating topical treatments for both adults and children experiencing acute otitis externa. As pre-established, trials focusing on chronic suppurative otitis, malignant, fungal, viral, or necrotizing otitis externa were excluded.

Eligible trials involved comparisons between topical antibiotic treatments and non-antibiotic alternatives, such as antiseptics, steroids, astringents, or herbal remedies. Co-interventions, including ear cleaning, were permitted.

Two reviewers employed the Cochrane Handbook for Systematic Reviews of Interventions to independently appraise RCT quality. Quality assessments encompassed randomization, blinding, follow-up, and outcome measurement, with an overall risk of bias summarized in a RoB2 traffic plot.


Seventeen meticulously selected trials aligned with the predefined inclusion criteria, demonstrating a robust foundation for the subsequent analysis. Out of this pool, ten trials underwent thorough scrutiny and became integral components of the comprehensive meta-analysis. The primary objective of this analytical endeavor was to amalgamate data, allowing for a meticulous comparison of the therapeutic efficacy between antiseptic and steroid monotherapies against topical antibiotic agents in the context of acute otitis externa.

Pooling the data enabled a nuanced examination of cure rates, a pivotal metric in assessing the success of interventions. Strikingly, the comparative analysis across various pairs of treatments revealed a lack of statistically significant differences in cure rates. This intriguing finding suggests a certain equipoise in the effectiveness of antiseptic and steroid monotherapies when juxtaposed with topical antibiotic treatments.

Notably, the individual trials, when taken in isolation, exhibited a trend favoring the efficacy of topical antiseptics or steroids over their antibiotic counterparts. However, the amalgamation of these diverse findings into the meta-analysis context unveiled a more intricate narrative. The cumulative data from all trials, when subjected to rigorous statistical scrutiny, did not yield conclusive evidence of a significant superiority of either antiseptics or steroids compared to antibiotics in terms of curing acute otitis externa.

This intriguing outcome underscores the nuanced nature of treatment responses and the importance of considering the collective body of evidence. It suggests that while individual studies may lean towards certain treatments, the broader synthesis of data, as achieved through meta-analysis, tempers these inclinations and emphasizes the need for a comprehensive understanding of the overall treatment landscape. This emphasizes the necessity for ongoing research endeavors, ensuring a dynamic and evolving approach to the management of acute otitis externa based on the most robust and up-to-date evidence available.

Final Thoughts

The treatment landscape for acute otitis externa encompasses a range of therapeutic options, including antiseptic, steroid, and antibiotic monotherapies, each demonstrating viability in addressing this inflammatory condition. Antiseptic agents contribute to the management of acute otitis externa by exerting antimicrobial effects, targeting the causative bacteria, and promoting a reduction in inflammation. Steroids, recognized for their anti-inflammatory properties, play a crucial role in alleviating symptoms associated with otitis externa, such as itching and pain. Antibiotics, designed to combat bacterial infections, are commonly employed to address the microbial component of acute otitis externa.

Despite the availability of these diverse treatment modalities, the current body of evidence does not decisively lean towards establishing the superiority or inferiority of topical antiseptic or steroid agents when compared to their antibiotic counterparts. The nuanced nature of individual cases, coupled with variations in patient response, complicates the determination of a clear hierarchy among these treatment options. As a result, the decision-making process for selecting an appropriate therapeutic approach should be guided by a comprehensive assessment of the patient’s specific condition, considering factors such as the severity of symptoms, microbial involvement, and individual responsiveness to different agents.

Ongoing research and clinical studies are crucial in expanding our understanding of the nuanced effectiveness of these treatment options, shedding light on optimal strategies for managing acute otitis externa. Until a more conclusive body of evidence emerges, healthcare practitioners must rely on a personalized and evidence-informed approach, tailoring treatments to individual patient needs and considering the evolving landscape of medical knowledge in the field of otolaryngology.

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