• Scenario: Acute diffuse otitis externa: covers the initial management of acute diffuse otitis externa, and what to do when initial treatment has failed.
• Scenario: Chronic diffuse otitis externa: outlines the management of chronic otitis externa, that is otitis externa that has persisted for more than 3 months.
• Scenario: Localized otitis externa: covers the management of folliculitis or a furuncle in the external ear canal.

• 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

• Assess presence of precipitating and risk factors, severity of symptoms and inflammation, and patency of tympanic membrane as for acute otitis externa. In addition assess for:
• Severity of itching — usually the most prominent symptom — and signs of scratching.
• Signs of fungal infection on examining the ear canal — whitish cotton-like strands of Candida, small black or white balls of Aspergillus.
• Signs of generalized dermatitis — mild erythema and lichenification (thickening of the skin) in the ear canal, and signs of underlying disease elsewhere (e.g. seborrhoeic dermatitis, psoriasis).
• Evidence of contact allergy or sensitivity — use of ear plugs, hearing aid, earrings, sensitizing medications (topical and systemic).
• Evidence of a source for an id (auto eczematization) reaction — a focus of fungal infection elsewhere in the body (e.g. skin, nails, vagina) can cause a secondary inflammatory process in the external ear canal.

In depth

• Laboratory investigations are rarely useful. However, if the treatment strategy fails, consider taking an ear swab for bacterial and fungal microscopy and culture.

In depth

• Apply general measures to keep the ear canal dry and free of debris and discharge while avoiding injuring it; relieve itch and pain; remove any precipitating antigens or irritants; treat any underlying skin condition such as seborrhoeic dermatitis. See Initial management for acute diffuse otitis externa.
• Treatment may be difficult, and may require trials of more than one strategy.
• If fungal infection is suspected (signs of fungal growth in ear canal) — prescribe a topical antifungal preparation and seek specialist advice if there is inadequate response.
• If the cause seems to be seborrhoeic dermatitis — treat topically with an antifungal–corticosteroid combination.
• If no cause is evident:
• Prescribe a 7-day course of a topical preparation containing only a corticosteroid without antibiotic. Consider co-prescribing an acetic acid spray.
• If there is an adequate response:
• The corticosteroid treatment may need to be continued. Reduce the potency of the corticosteroid and/or the frequency of application to the minimum required to maintain control.
• If treatment cannot be withdrawn after 2 or 3 months, seek specialist advice.
• If the response is inadequate, consider a trial of a topical antifungal preparation.

In depth

• If otitis externa does not respond to appropriate treatment in primary care.
• If contact sensitivity is suspected and patch testing would be useful to guide further management.
• If the ear canal is occluded or becoming occluded.
• If malignant otitis is suspected.

In depth

• Review response after completion of a course of treatment.
• People with diabetes or compromised immunity are at increased risk for complications and should be followed up more closely.

In depth

• Treat pain with an analgesic and the application of local heat (e.g. a warm flannel).
• Treat infection with an oral antibiotic ONLY if there is severe infection, or the person is at high risk of severe infection, (e.g. they have poorly-controlled diabetes, or compromised immunity).
• Drain pus if it has collected and is causing severe pain and swelling.
• Advise on ear care and hygiene.

In depth

• No follow up is necessary for most cases of acute localized otitis externa as they are mild and self limiting.
• Consider follow up if an antibiotic has been prescribed, or if there are risk factors such as insulin-dependent diabetes or compromised immunity.

In depth

• Consider referral to secondary care:
• If relief of pain and swelling requires incision and drainage of the furuncle, and the resources and skills are not available in primary care.
• If there is inadequate response to oral antibiotic treatment.
• If cellulitis is spreading outside the auditory canal.

In depth