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Otitis externa - Management
How should I manage treatment failure of acute diffuse otitis externa?

  • Review the diagnosis and exclude and manage other conditions.
  • Assess and manage ongoing triggers (e.g. exposing ears to moisture, trauma to the ear canal by attempts to clean or scratch it).
  • Review compliance with medication.
    • Reinforce advice on administering drops or ointment.
    • Consider repeating treatment, or switching from a drop preparation to a spray or vice versa.
  • Assess factors that would impede delivery of topical medication to affected areas.
    • If there is extensive discharge, consider gentle irrigation (provided the tympanic membrane is intact), or microsuction (which might require referral).
    • If there is extensive swelling of the auditory canal, consider referral for insertion of an ear wick or initiation of a systemic antibiotic.
  • If contact dermatitis due to neomycin or other aminoglycoside is suspected:
    • Consider switching to a preparation which does not contain an aminoglycoside — see Available preparations.
    • Consider referral to a dermatologist for patch testing to confirm sensitivities.
  • If there are systemic signs of infection, or if the infection is spreading outside the ear canal, prescribe a 7-day course of an oral antibiotic, (i.e. flucloxacillin; or erythromycin if penicillin sensitive; or clarithromycin if erythromycin and flucloxacillin are both contraindicated).
  • If these measures have been tried, or are not applicable:
    • Consider culturing a specimen of the ear canal to identify fungi and resistant bacteria.
    • Consider the possibility of a fungal infection and treat with topical preparation containing an antifungal such as clotrimazole 1% ear drops (Canesten®), or flumetasone pivalate 0.02%, clioquinol 1% ear drops (Locorten–Vioform®).
  • Otherwise seek specialist advice.
Basis for recommendation

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