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Summary for primary care

Otitis Externa

Overview

This Guidelines summary covers recommendations on diagnosing, assessing, and managing otitis externa. It also includes a useful table containing available topical ear preparations.

Latest Guidance Updates

February 2022: updates to the topical preparations table.

Diagnosis

When Should I Suspect Acute Otitis Externa? 

  • Suspect a diagnosis of acute otitis externa if a person presents with: 
    • At least one typical symptom (usually rapid-onset within 48 hours):
      • Itch of the ear canal.
      • Ear pain and tenderness of the tragus and/or pinna (often severe), with possible jaw pain.
      • Ear discharge.
      • Hearing loss due to ear canal occlusion (less common).
    • At least two typical signs:
      • Tenderness of the tragus and/or pinna.
      • The ear canal is red and oedematous, and there may be debris and ear discharge contributing to swelling and canal occlusion.
      • Tympanic membrane erythema (may be difficult to visualize if the ear canal is narrowed or filled with debris).
      • Cellulits of the pinna and adjacent skin. See the CKS topic on Cellulitis - acute for more information.
      • Conductive hearing loss (less common).
      • Tendor regional lymphadenitis (less common).

Assessment

How Should I Assess a Person With Suspected Otitis Externa?

  • If a person has suspected otitis externa:
    • Ask about:
      • The onset, nature, and severity of symptoms, such as:
        • Pain or tenderness on moving the ear (tragus or pinna) or jaw.
        • Ear discharge.
        • Itch in the ear canal.
        • Fever.
        • Hearing loss (conductive).
      • Impact on daily functioning and quality of life.
      • Any possible causes or risk factors, including recent ear trauma, use of hearing aids or ear plugs, history of head or neck radiotherapy.
      • Any previous episodes and topical or oral treatments used.
      • Any previous ear surgery, perforation of the tympanic membrane and/or tympanostomy tube insertion within the previous year.
      • Any history of allergic or irritant contact dermatitis. See the CKS topic on Dermatitis - contact for more information.
      • Any comorbidities such as diabetes mellitus or other causes of immunocompromise. See the CKS topics on Diabetes - type 1 and Diabetes - type 2 for more information.
    • Examine the person’s ears, starting with the unaffected or less affected ear:
      • Assess the ear canal, tympanic membrane, pinna, auricular, and cervical lymph nodes for possible signs:
        • Red, oedematous ear canal which may be narrowed and obscured by debris.
        • Ear discharge (serous or purulent).
        • Signs of fungal infection (such as white strands of Candida, or small black or white balls of Aspergillus).
        • Regional lymphadenopathy.
        • Cellulitis spreading beyond the ear. See the CKS topic on Cellulitis - acute for more information.
      • Assess for perforation of the tympanic membrane, including a tympanostomy tube in situ.
      • Assess the surrounding skin for associated skin disorders suggesting a possible underlying cause or alternative condition.
      • Note: it can be difficult to adequately visualize the tympanic membrane on initial presentation.
    • Consider arranging an ear swab for bacterial and fungal microscopy, culture, and sensitivity if there is:
      • Treatment failure. See the section on Treatment failure for more information.
      • Severe, recurrent, or chronic otitis externa.
      • Ear canal occlusion due to swelling and debris, causing difficulty using topical treatment effectively.
      • Suspected spread of infection beyong the external ear canal.

Differential Diagnosis

What Else Might It Be?

Other conditions that may present similarly to acute otitis externa include:
  • Acute otitis media — may present with an erythematous tympanic membrane and ear discharge (particularly if a tympanostomy tube is in situ). See the CKS topic on Oititis media with effusion for more information.
  • Foreign body in the ear (especially in children) may present with purulent ear discharge and pain.
  • Impacted ear wax — may cause pain and hearing loss. See the CKS topic on Earwax for more information.
  • Skin conditions — such as contact dermatitis, eczema, fungal skin infection, psoriasis, seborrhoeic dermatitis, erysipelas, and discoid lupus erythematosus involving the ear canal. See the CKS topics on Dermatitis - contactEczema - atopicFungal skin infection - body and groinPsoriasis, and Seborrhoeic dermatitis for more information.
  • Referred pain — may originate from the teeth, sphenoidal sinus, neck, or throat. See the CKS topics on Dental abscessGingivitis and periodontitisSinusitis, and Sore throat - acute  for more information.
  • Cholesteatoma — causes persistent or recurrent ear discharge and fullness, but is typically painless. There may be a perforated tympanic membrane, retraction pocket in the tympanic membrane, and granulation tissue, which may mimic malignant otitis externa. See the CKS topic on Cholesteatoma for more information.
  • Ramsay Hunt syndrome — a form of herpes zoster affecting the facial nerve, which may present with severe pain, vesicles on the external ear canal and posterior pinna, facial paralysis, loss of taste on the anterior two-thirds of the tongue, and decreased lacrimation on the involved side. See the CKS topic on Shingles for more information.
  • Barotrauma — such as in divers, recent air travel, or recent ear trauma.
  • Malignancy — squamous cell carcinoma of the ear canal can present similarly to malignant otitis externa, with abnormal tissue growth in the ear canal or bloody ear discharge.

Management of Acute Otitis Externa

From age 3 months onwards.

Initial Management

How Should I Manage a Person with Acute Otitis Externa?

If a person presents with acute otitis externa:

  • Provide advice on sources of information and support, such as:
  • Provide advice on self-care measures for symptom relief and to reduce risk of recurrent infection.
    • Avoid damage to the external ear canal:
      • Troublesome ear wax should be removed safely to avoid damaging the ear canal. Cotton buds or other objects should not be used to clean the ear canal.
    • Keep the ears clean and dry.
      • Avoid swimming and water sports for at least 7–10 days furing treatment.
      • Use ear plugs and/or a tight-fitting cap when swimming.
      • Keep shampoo, soap, and water out of the ear when bathing and showering, for example by inserting ear plugs or cotton wool (with petroleum jelly).
      • Consider using a hair dryer (at the lowest heat setting) to dry the ear canal after hair washing, bathing, or swimming.
    • Consider use of over-the-counter acetic acid 2% ear drops or spray (for people aged 12 years and older) morning, evening, and after swimming, showering, or bathing, for a maximum of 7 days. See the section, Topical ear preparations for more information on other available antiseptic and astringent ear preparations.
  • Manage any underlying causes or risk factors including associated skin conditions, where possible.
    • If the person is allergic or has contact sensitivity to ear drops such as neomycin, ear plugs, hearing aids, or earrings, they should avoid use, or use alternatives where available (such as hypoallergic hearing aids). 
  • Advise on options for analgesia such as paracetamol or ibuprofen for symptom relief, if needed.
  • Consider cleaning the external auditory canal (‘aural toilet’), to enable topical treatments to be applied effectively. Options include:
    • Dry swabbing of secretions.
    • Ear irrigation to remove debris, earwax, and exudate, if the tympanic membrane is visualized and intact and the person is not immunocompromised.
  • Consider prescribing a topical antibiotic preparation with or without a topical corticosteroid for 7–14 days, depending on clinical judgement and symptom response.
    • The choice of drug treatment should be guided by personal preference, risk of adverse effects including ototoxicity, cost, dosing frequency, and whether the tympanic membrane is intact (if visualized).
    • An additional topical corticosteroid preparation may be beneficial if there is significant inflammation, erythema, and oedema in the ear canal.
    • Advise on how to administer ear drops correctly.
    • See the section on Topical ear preparations in Prescribing information for more information on available preparations, how to administer, and contraindications to use.
  • Consider prescribing an oral antibiotic if the person is immunocompromised, there is severe infection, or there is spread beyond the external ear canal to adjacent tissues, depending on clinical judgement. See the CKS topic on Cellulitis - acute for more information on how to diagnose cellulitis.
    • A quinolone antibiotic such as ciprofloxacin may be needed, depending on local prescribing guidelines.
  • Arrange follow up to reassess the person if:
    • Symptoms are not improving within 48–72 hours of starting initial treatment.
    • Symptoms have not fully resolved after 2 weeks of starting initial treatment.
    • Symptoms are severe and/or there is cellulitis spreading beyond the external ear canal. See the CKS topic on Cellulitis - acute for more information.
    • The person is immunocompromised and at risk of severe infection, depending on clinical judgement.
    • There is ear wax impaction or stenosis of the ear canal which prevents the tympanic membrane being visualized, to check for an alternative cause for symptoms.

Treatment Failure

How Should I Manage Treatment Failure of Acute Otitis Externa?

If a person has had initial management of acute otitis externa and symptoms persist:
  • Assess for associated or alternative conditions which may be causing ongoing symptoms.
  • Reassess for any underlying causes or risk factors including associated skin conditions, where possible.
  • Ensure the person is following advice on self-care measures. See the section on Initial management for more information.
  • Ensure the person is using any topical drug treatment correctly.
    • Consider switching from an ear drop to ear spray preparation (or vice versa), depending on clinical judgement.
    • If contact sensitivity to neomycin or another aminoglycoside ear drop is suspected, consider switching to a preparation which does not contain an aminoglycoside.
  • Re-examine the person.
    • Assess for ear canal occlusion due to ear discharge, swelling, or debris which may stop topical treatment working effectively.
    • Assess for signs of fungal ear infection, foreign body, tympanic membrane perforation, or middle ear disease, and treat appropriately.
    • Assess for signs of systemic illness or infection spreading beyond the external ear canal. See the CKS topic on Cellulitis - acute for more information.
      • Consider prescribing an oral antibiotic if infection has spread beyond the external ear canal to adjacent tissues. See the section on Initial management for more information.
  • Consider cleaning the external ear canal (‘aural toilet’), to enable topical treatments to be applied effectively. Options include:
    • Dry swabbing of secretions.
    • Ear irrigation to remove debris, earwax, and exudate, if the tympanic membrane is visualized and intact.
  • Consider arranging an ear swab for bacterial and fungal microscopy, culture, and sensitivity, and arrange treatment depending on the result.
    • See the section on Assessment for more information.
  • Consider the need to seek specialist advice or arrange specialist referral.
    • See the section on Specialist advice for more information.

Specialist Advice or Referral

When Should I Seek Specialist Advice or Refer for Acute Otitis Externa?

  • Arrange emergency hospital admission or urgent referral to an ear, nose, and throat (ENT) specialist if:
    • Malignant otitis externa or a serious complication is suspected, depending on clinical judgement.
  • Seek specialist advice or arrange referral to an ENT specialist, the urgency depending on clinical judgement, if:
    • Symptoms persist despite optimal management in primary care. See the section on Treatment failure for more information.
    • There is severe infection not responding to management in primary care.
    • The person is elderly, has poorly controlled diabetes mellitus or another cause of immunocompromise, depending on clinical judgement.
    • There is external ear canal occlusion due to ear discharge, swelling, or debris which is stopping topical treatment working effectively.
      • Specialist ‘aural toilet’ including microsuction, ear wick insertion, or use of systemic antibiotics may be needed.
    • There is cellulitis extending beyond the external ear canal which cannot be managed in primary care. See the CKS topic on Cellulitis - acute for more information.
      • Systemic antibiotics may be needed, following specialist advice.
  • Consider referral to a dermatology specialist if contact sensitivity to neomycin or another aminoglycoside ear preparation, ear plugs, hearing aids, or earrings, is suspected.
    • Patch testing to confirm contact sensitivities may be needed.

Management of Chronic Otitis Externa

Initial Management

How Should I Manage a Person with Chronic Otitis Externa?

If a person presents with chronic otitis externa:
  • Provide advice on sources of information and support, such as:
  • Reinforce advice on self-care measures for symptom relief and to reduce risk of recurrent infection.
    • See the section on Initial management in the section on Acute otitis externa for more information.
  • Manage any underlying causes or risk factors including associated skin conditions, where possible.
    • If the person has irritant or allergic contact dermatitis or sensitivity to topical preparations (such as neomycin ear drops), ear plugs, hearing aids, or earrings, advise to avoid contact with the irritant or allergen where possible. See the CKS topic on Dermatitis - contact for more information on management.
  • Advise on options for analgesia such as paracetamol or ibuprofen for symptom relief, if needed.
  • Consider arranging an ear swab for bacterial and fungal microscopy, culture, and sensitivity, and arrange treatment depending on the result.
    • See the section on Assessment for more information.
  • Consider cleaning the external auditory canal (‘aural toilet’), to enable topical treatments to be applied effectively. Options include:
    • Dry swabbing of secretions.
    • Ear irrigation to remove debris, earwax, and exudate, if the tympanic membrane is visualized and intact.
  • Consider prescribing a topical ear preparation, depending on clinical judgement.
    • If there are signs of fungal infection in the ear canal, options include:
      • A topical antifungal preparation, such as clotrimazole 1% solution applied 2–3 times a day, to be continued for at least 14 days after infection has resolved.
      • Clioquinol and a corticosteroid 2–3 drops twice daily for 7–10 days.
      • Over-the-counter acetic acid 2% ear drops or spray (off-label indication, for people aged 12 years and older) morning, evening, and after swimming, showering, or bathing, for a maximum of 7 days.
    • If there is suspected bacterial infection, manage as for acute otitis externa.
      • See the section on Acute otitis externa for more information.
    • If there is no obvious fungal or bacterial infection:
      • Consider prescribing a topical corticosteroid preparation such as prednisolone ear drops 2–3 drops every 2–3 hours until symptoms improve, or betamethasone ear drops 2–3 drops 3–4 times a day. If symptoms improve, continue treatment using the lowest potency and/or frequency of application needed to control symptoms.
      • If symptoms persist despite topical corticosteroid treatment, consider a trial of a topical antifungal preparation instead.
    • See the section, Topical ear preparations more information on available preparations and how to administer, and refer to the full Clinical Knowledge Summary for information on contraindications to use.
  • Arrange follow up to reassess the person, depending on clinical judgement, if:
    • Symptoms persist or are worsening despite treatment in primary care.
    • The person is immunocompromised and at risk of malignant otitis externa or other complications.
  • Consider the need to seek specialist advice or arrange specialist referral.
    • See the section on Specialist advice or referral for more information.

Specialist Advice or Referral

When Should I Seek Specialist Advice or Refer for Chronic Otitis Externa?

  • Arrange emergency hospital admission or urgent referral to an ear, nose, and throat (ENT) specialist if:
    • Malignant otitis externa or a serious complication is suspected, depending on clinical judgement.
  • Seek specialist advice or arrange referral to an ENT specialist, the urgency depending on clinical judgement, if:
    • Symptoms persist despite optimal management in primary care. See the section on Initial management for more information.
    • Ongoing topical treatment is needed for symptom control beyond 2–3 months. See the section on Initial management for more information.
    • The person is elderly, has poorly controlled diabetes mellitus or another cause of immunocompromise, depending on clinical judgement.
    • There is ear canal occlusion due to ear discharge, swelling, or debris which is causing difficulty using topical treatment effectively.
      • Specialist microsuction or ear wick insertion may be needed.
    • There is cellulitis extending beyond the external ear canal which cannot be managed in primary care. See the CKS topic on Cellulitis - acute for more information.
      • Systemic antibiotics may be needed, following specialist advice.
  • Consider referral to a dermatology specialist if contact sensitivity to neomycin or another aminoglycoside ear preparation, ear plugs, hearing aids, or earrings, is suspected.
    • Patch testing to confirm contact sensitivities may be needed.

Topical Ear Preparations

Table 1: Topical Ear Preparations Available in the UK for Treating Otitis Externa

GroupProducts
Astringent/acidic Preparations  
Astringent/acidicAluminium acetate 8%[A] and 13% drops; combined acetic acid 8.25% with aluminium acetate and aluminium acetotartrate 1.8% spray (Otinova®)[B]
Acetic acid 2% spray (Earcalm®)[B]
Corticosteroid Preparations
Corticosteroid: lower potencyPrednisolone sodium phosphate 0.5% drops (Prefsol®)
Corticosteroid: higher potencyBetamethasone sodium phosphate 0.1% drops (Betnesol®, Vista-methasone®)
Antibiotic Preparations
Aminoglycoside    Gentamicin 0.3% drops (Genticin®)
FluoroquinoloneCiprofloxacin 2mg/ml (Ciloxan®, Cetraxal®)
Antifungal Preparations
AntifungalClotrimazole 1% solution (Canesten®)
Combined Corticosteroid and Antibiotic Preparations
CiprofloxacinCiprofloxacin 0.3%, dexamethasone 0.1% ear drops
Fluocinolone 0.25mg/ml, ciprofloxacin 3mg/ml (Cetraxal plus®)
Aminoglycoside with Corticosteroid
NeomycinBetamethasone sodium phosphate 0.1%, neomycin sulphate 0.5% (drops: Betnesol-N®, Vista-Methasone N®)
Hydrocortisone 1%, neomycin sulphate 3400 units, polymyxin B sulphate 10,000 units/mL (drops: Otosporin®)
Prednisolone sodium phosphate 0.5%, neomycin sulphate 0.5% (drops: Predsol-N®)
Dexamethasone 0.1%, neomycin sulphate 3250 units/mL, glacial acetic acid 2% (spray: Otomize®)
GentamicinHydrocortisone acetate 1%, gentamicin 0.3% (drops: Gentisone HC®)
FramycetinDexamethasone 0.05%, framycetin sulphate 0.5%, gramicidin 0.005% (drops: Sofradex®)
Combined Corticosteroid and Antibiotic/antifungal Preparations
Clioquinol with corticosteroidFlumetasone pivalate 0.02%, clioquinol 1%
[A] Aluminium acetate 8% can be made by diluting 8 parts aluminium acetate ear drops (13%) with 5 parts purified water (must be freshly prepared before use).[B] Available to buy over-the-counter.

What Advice Should I Give About Administering Ear Drops?

  • If possible, ask the person to allow another person to administer a topical ear preparation.
    • Warm the drops to body temperature by holding the bottle in the hands or pocket for a few minutes (to reduce the risk of adverse effects such as dizziness which can occur if cold drops are administered). 
    • To administer the ear drops to ensure optimal delivery throughout the external ear canal:
      • The person should lie down with the ear to be treated uppermost.
      • The ear canal should be filled with ear drops. Gently pulling and pushing the ear helps to let air out of, and liquid into, the ear canal.
      • The person should remain in this position for 3–5 minutes.
      • If the person cannot lie still long enough to allow absorption, a small cotton plug covered with petroleum jelly or moistened with the drops and placed at the external opening of the ear canal for about 5 minutes can be used to help retain the drops in the ear.
      • A small cotton swab placed at the tragus can be used to catch any leakage from the ear when sitting up.
      • The ear canal should be left open to dry.

For recommendations on contraindications for topical ear preparations, refer to the full Clinical Knowledge Summary.


References


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