• Investigations are rarely useful. However, if treatment fails or otitis externa recurs frequently, consider sending an ear swab for bacterial and fungal microscopy and culture.

In depth

• 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:
• Both a non-aminoglycoside antibiotic and a corticosteroid e.g. flumetasone–clioquinol (Locorten–Vioform^®) ear drops.
• Both an aminoglycoside antibiotic and a corticosteroid (contraindicated if the tympanic membrane is perforated).
• Topical preparations containing only an antibiotic (gentamicin ear drops are contraindicated if the tympanic membrane is perforated).
• 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).
• Provide appropriate self-care advice.

In depth

• Gentle syringing or irrigation — to remove debris, provided that the tympanic membrane is intact; regarded as controversial by some experts.
• Dry swabbing — to gently mop out thin secretions from the external auditory canal.
• Microsuction — if irrigation and swabbing are ineffective or inappropriate. Microsuction will usually require referral to secondary care.

In depth

• Avoid damaging the external ear canal.
• Keep the ears dry and clean.
• Avoid ear drops containing neomycin if of an allergic disposition.
• If skin is irritated by ear plugs, hearing aids, or ear rings, seek advice from a healthcare professional.
• Treat any skin condition such as eczema, psoriasis.
• Consider using acidifying ear drops or spray (no prescription is needed).

In depth

• Consider follow up for people with diabetes or compromised immunity, or with cellulitis which has spread outside the auditory canal.

In depth

• Admit urgently if malignant otitis is suspected.
• Consider seeking specialist advice if:
• Symptoms have not improved despite treatment and treatment failure is unexplained.
• Treatment with a quinolone is indicated.
• Consider referral to secondary care if there is:
• Extensive cellulitis.
• Extreme pain or discomfort.
• Considerable discharge or extensive swelling of the auditory canal, and microsuction or ear wick insertion is required.

In depth

• 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).
• Assess and manage any compliance problems.
• Assess and manage factors that would impede delivery of topical medication to affected areas.
• If contact dermatitis due to neomycin or other aminoglycoside is suspected, consider switching to a preparation which does not contain an aminoglycoside.
• If there are systemic signs of infection, or if the infection is spreading outside the ear canal, prescribe 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.

In depth