Print Print
CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.

Otitis externa - Management
How should I treat localized otitis externa?

  • Treat pain:
    • Treat with an analgesic and the application of local heat (e.g. a warm flannel). These measures are sufficient for most cases of localized otitis externa as folliculitis is usually mild and self limiting.
  • Treat infection if necessary:
    • Only consider an oral antibiotic for people with severe infection, or at high risk for severe infection, for example if:
      • Furunculosis or cellulitis spreads beyond the ear canal to the pinna, neck, or face.
      • There are systemic signs of infection, such as fever.
      • The person has a condition (e.g. poorly-controlled diabetes or compromised immunity) that is associated with increased risk of severe infection.
  • Drain pus if necessary:
    • If pus is causing severe pain and swelling, consider incision and drainage.
      • This is rarely required.
      • Incision and drainage usually requires referral, although a small pustule near the entrance to the ear canal may be drained by incising it with a surgical needle.
  • Advise on ear hygiene:
    • Minimize trauma to ear canal: no scratching with anything and no cleaning with cotton buds.
Clarification / Additional information
  • Oral antibiotics are rarely indicated.
    • 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 cannot tolerate erythromycin.
Basis for recommendation
  • CKS found no evidence or guidelines specifically on furunculosis in the external ear canal.
  • These recommendations are therefore pragmatic advice, based on the most likely causative organism (Staphylococcus aureus) and expert opinion from the medical literature on how furunculosis should be treated [Laube, 2004; Sladden and Johnston, 2005; McNulty, Personal Communication, 2006].
  • Oral antibiotics
    • CKS found no direct evidence from placebo-controlled trials.
    • 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.

© NHS Institute for Innovation and Improvement