NICE provide a Clinical Knowledge Summary on this topic.
Symptoms of otitis externa are ear pain, pruritus, discharge, and hearing loss, often after water exposure (swimmer’s ear), instrumentation (cotton buds) or use of occluding devices (bud ear phones).
Aural toilet is an essential component of treatment; it facilitates healing and improves penetration of ear drops.
If first line topical treatment has failed, consider taking an ear swab for bacterial and fungal culture. Review any culture results and ensure that an appropriate antibiotic has been prescribed.
| Infection |
| Otitis externa |
| Therapy |
|
First line Analgesia and localised heat (warm flannel). Second line A proprietary preparation containing acetic acid 2% (EarCalm® spray) is on sale to the public, or betamethasone with neomycin eardrops: apply 2 - 3 drops 3 - 4 times a day for 7 days If cellulitis is present, or disease extends outside the ear canal Flucloxacillin oral 250-500mg 6 hourly for 5 days or Clarithromycin oral 250-500mg 12 hourly for 5 days N.B. Clarithromycin should not be prescribed concurrently with ciclosporin, sirolimus or tacrolimus. If systemic antibiotics are thought to be required for treatment, or if there is cellulitis extending from the ear canal or the ear canal is occluded, seek advice from a specialist to exclude malignant otitis externa. |
NICE has produced a useful Clinical Knowledge Summary on management of chronic otitis externa.
P. aeruginosa is a common cause of chronic otitis externa. P. aeruginosa is never reported susceptible ("S") to ciprofloxacin, but can only be susceptible at increased dose ("I") or resistant ("R").
Malignant (necrotizing) otitis externa usually develops in elderly diabetic patients or other immunocompromised individuals; in these cases the infection spreads to the soft tissue, cartilage, and bone of the temporal region and skull base. Patients with malignant otitis have severe pain and otorrhoea, and cranial nerve palsies may be present; on examination, there is granulation tissue in the floor of the ear canal.
These patients should be referred promptly to ENT.
| Guideline reviewed | August 2023 |
| Page updated | February 2024 |