Tympanotomy tube Otorrhea (TTO)
Otitis with PE tubes

1. Treat (uncomplicated):
•	Ciprodex -4 drops in affected ear BID F7
•	If fails topical therapy after 3-5 days, trial of PO antibiotic or referral to ENT for culture may be warranted.

Fluoroquinolone containing drops (eg, ofloxacin and ciprofloxacin-dexamethasone) are the only topical antimicrobials approved by the US Food and Drug Administration (FDA) for treating otorrhea with a nonintact tympanic membrane

Administration of eardrops — Antibiotic eardrops work well when instilled into a thoroughly cleaned ear with a patent tympanostomy tube. It is less clear whether they work when applied over a collection of pus from a rapidly discharging AOM [65,66]. In an observational study using an in vitro model, eardrops instilled into a clean external ear canal did not consistently pass through the tympanostomy tube; entry into the middle ear was facilitated by application of slight tragal pressure [66].

Ideally, the ear canal should be cleaned by the clinician with suction or repeated cotton swabbing before instilling drops. Having the child lie down with the affected ear up for a few moments promotes penetration. The optimal number of drops has not been established. According to the package inserts, the dose for ofloxacin is five drops and for ciprofloxacin-dexamethasone is four drops.



2. Treat (Complicated acute TTO) — We suggest oral or parenteral antibiotics for ill-appearing infants and older children with acute TTO and systemic infection or severe symptoms (eg, fever, lethargy, severe ear pain, copious otorrhea, associated upper respiratory symptoms) [43,45]. We also suggest systemic antimicrobial therapy for TTO in immunocompromised children and TTO associated with occlusion of the auditory canal [1,41,43,45]. The antibiotic should have activity against the common pathogens of AOM (eg, S. pneumoniae, M. catarrhalis, H. influenzae). We suggest high dose amoxicillin (75 to 100 mg/kg/day divided twice daily) or amoxicillin-clavulanate (with high dose amoxicillin) as empiric therapy