General Measures

• Keep ear canal dry and free of debris and discharge while avoiding injuring it.
• Relieve itch and pain.
• Remove any precipitating antigens or irritants (such topical aminoglycoside), or devices (such as ear plugs, hearing aids, or ear rings).
• Treat any underlying skin condition such as seborrhoeic dermatitis, eczema, psoriasis.

Acute localised otitis externa

• Treat pain with an analgesic and the application of local heat (e.g. a warm flannel).
• Only consider an oral antibiotic for people with severe infection, or at high risk for severe infection.
• If pus is causing severe pain and swelling, consider incision and drainage (usually requires referral).

Acute diffuse otitis externa

• Treat any underlying skin condition such as eczema or psoriasis.
• Offer analgesics (e.g. paracetamol or ibuprofen) for pain.
• Treat with a topical ear preparation — there is insufficient evidence to prefer one preparation over another.
• Consider specialist referral for cleaning (microsuction) and/or insertion of an ear wick if these are necessary for severe infection.

Chronic otitis externa

• Treat any evidence cause (e.g. contact dermatitis, seborrhoeic dermatitis).
• If no cause is evident (as is the usual case):
• Treat with a 7-day course of a topical preparation containing only a corticosteroid without antibiotic; consider an acetic acid spray at the same time.
• If there is an adequate response, treatment may need to be continued for 2–3 months.
• If the response is inadequate, consider a topical antifungal.
• Consider specialist referral when:
• Otitis externa does not respond to appropriate treatment in primary care.
• Contact sensitivity is suspected and patch testing would be useful to guide further management.
• The ear canal is occluded or becoming occluded.
• Malignant otitis is suspected.