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Otitis externa - Management
How should I treat acute diffuse otitis externa?

  • Remove or treat any precipitating or aggravating factors.
  • Prescribe or recommend an analgesic for symptomatic relief.
    • Paracetamol or ibuprofen are usually sufficient. Codeine can provide additional analgesia for severe pain.
  • Treat inflammation using a topical ear preparation for 7 days:
    • For mild cases (discomfort and/or pruritus; no pain, deafness, or discharge) topical acetic acid 2% spray can be used first-line.
    • For more severe cases (pain, deafness, discharge), or if treatment with acetic acid for mild otitis externa is not effective, a topical antibiotic with or without a topical corticosteroid should be used:
      • Topical preparation containing both a non-aminoglycoside antibiotic and a corticosteroid e.g. flumetasone–clioquinol (Locorten–Vioform®) ear drops.
      • Topical preparations containing both an aminoglycoside antibiotic and a corticosteroid.
      • Topical preparations containing only an antibiotic.
    • If there is sufficient earwax or debris to obstruct topical medication, consider cleaning the external auditory canal (may require referral).
    • If there is extensive swelling of the auditory canal, consider inserting an ear wick (may require referral).
    • Only consider adding an oral antibiotic for people with severe infection.
  • Provide appropriate self-care advice to aid recovery and to reduce risk of future infection.
Clarification / Additional information
  • Topical ear preparations:
    • The decision about which topical ear preparation to prescribe should take into account the risk of adverse effects, the person's preference, and cost.
    • Adverse effects to consider include aminoglycoside-induced ototoxicity in people with a perforated tympanic membrane, aminoglycoside-induced skin sensitization, and fungal superinfection (particularly with longer treatments).
  • Ear wick:
    • This is impregnated with the medication and is inserted into the auditory canal to aid drug delivery when the auditory canal is narrowed by swelling or debris.
    • Insertion requires referral (unless the equipment and expertise are available locally).
    • The ear wick should be changed at least every 2 or 3 days.
  • Oral antibiotics are rarely indicated.
    • Consider seeking specialist advice if an oral antibiotic is thought to be required, such as for:
      • Cellulitis extending beyond the external ear canal.
      • When the ear canal is occluded by swelling and debris, and a wick can not be inserted.
      • Diabetes or compromised immunity, and severe infection or high risk of severe infection, e.g. with Pseudomonas aeruginosa.
    • If an oral antibiotic is to be prescribed in primary care, the options to consider are a 7-day course of:
      • Flucloxacillin, or
      • Erythromycin, if the person is allergic to penicillin, or
      • Clarithromycin, if the person can not tolerate erythromycin.
Basis for recommendation
  • These recommendations on the management of acute diffuse otitis externa are based on the evidence-based recommendations issued by the American Academy of Otolaryngology — Head and Neck Surgery Foundation [American Academy of Otolaryngology et al, 2006], published reviews [Sander, 2001; Block, 2005; Osguthorpe and Nielsen, 2006; DynaMed, 2007], the Aural discharge patient pathway issued by Centre for Change and Innovation for NHS Scotland [NHS Scotland, 2005], and the CKS review of the supporting evidence.
  • Topical treatments:
    • There is evidence that topical treatments are effective, but insufficient evidence to prefer any antibiotic or corticosteroid preparation, or combination, over any other topical treatment on the basis of effectiveness.
      • There is evidence that topical corticosteroids are at least as effective as topical antibiotics combined with corticosteroids. However, because of methodological weaknesses in the clinical trials and because acute diffuse otitis externa is thought to be caused by an infection, topical corticosteroids on their own are not generally recommended as first-line treatment [American Academy of Otolaryngology et al, 2006; BNF 53, 2007].
      • There is evidence that topical aminoglycosides are ototoxic and may damage the inner ear, and they are therefore contraindicated if the tympanic membrane is perforated [CSM, 1997].
      • Topical aminoglycosides are less preferred by some experts because they can cause contact dermatitis, although this is rare after a short course for acute otitis externa [American Academy of Otolaryngology et al, 2006].
      • Chloramphenicol ear drops are not recommended because they cause contact dermatitis in about 10% of people [BNF 53, 2007].
      • Clioquinol is antibacterial and antifungal and has lower risks of skin reactions and ototoxicity than aminoglycosides. Therefore, on theoretical grounds, the combination flumetasone–clioquinol (Locorten–Vioform®) ear drops might be slightly preferred over preparations containing aminoglycosides — CKS found no direct evidence from comparative trials to support this.
      • Fluoroquinolone antibiotic ear drops (ciprofloxacin and ofloxacin) are unlicensed and only available on a named-patient basis. They might be initiated in secondary care for resistant cases of pseudomonal infection. The use of fluoroquinolone eye drops in the ear is an unlicensed indication [BNF 53, 2007].
    • The recommendation to use topical acetic acid first line for mild cases of acute diffuse otitis externa, but antibiotic-corticosteroid combinations for more severe cases is based on feedback from CKS expert reviewers.
      • There are no concerns with antibiotic resistance or fungal overgrowth with acetic acid, and the limited evidence available suggests that it has some efficacy, although this may not be as great as with an antibiotic-corticosteroid combination.
  • Analgesia:
  • Oral antibiotics:
    • CKS found no direct evidence from placebo-controlled trials, and no relevant evidence from clinical trials of adding oral antibiotics to topical treatment.
    • These recommendations are therefore based on guidelines on the management of acute otitis externa [American Academy of Otolaryngology et al, 2006], and the general principles of management of staphylococcal skin infections [Hay and Adriaans, 2004].
      • Otitis externa with furunculosis or spreading cellulitis is thought to be usually due to staphylococcal infection, as with furunculosis and cellulitis in other anatomical locations [Hay and Adriaans, 2004]. Although CKS found no evidence from clinical studies to support this assumption, it seems plausible.
      • Flucloxacillin has a narrow spectrum of activity, and is active against most susceptible Gram-positive cocci, including beta-lactamase-producing staphylococci and streptococci. However, it is not active against MRSA (meticillin-resistant Staphylococcus aureus). It diffuses well into most tissues, so is suitable for skin and soft tissue infections [Finch et al, 2003].
      • Erythromycin and clarithromycin have a broad spectrum of activity and are active against most sensitive Gram-positive cocci (including staphylococci and streptococci) and some Gram-negative cocci and anaerobes [Finch et al, 2003].
      • Clarithromycin may be used in people who are known not to tolerate erythromycin. It is more effective against common pathogens than erythromycin, and has fewer gastrointestinal adverse effects [Finch et al, 2003]. However, it is markedly more expensive than erythromycin.
      • Quinolones are not recommended for use in primary care because, if the person is thought to be at high risk for pseudomonal infection, they should be referred to a specialist.
    • These recommendations may differ considerably from UK practice. In 1997, general practitioners prescribed oral antibiotics for 21% of first episodes of otitis externa. Amoxicillin/ampicillin was the most frequently prescribed antibiotic (34%) [Rowlands et al, 2001]. The authors did not discuss the appropriateness of the prescribing patterns. CKS was unable to find more recent data.

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