Signs and Symptoms

Furuncle of the external auditory meatus

• Localised swelling in the ear canal, exquisitely tender.
• Sudden relief of pain if the furuncle bursts — rare.

Acute diffuse otitis externa

• Lasting less than 3 weeks.
• The ear canal or external ear, or both, are red, swollen.
• Discharge may be present in the ear canal.
• Eardrum may be difficult to visualise if the ear canal is narrowed or filled with debris.
• Pain on moving the ear or jaw.

Chronic otitis externa

• Lasting more than 3 months.
• Dry hypertrophic skin.
• Pain on manipulation of the external ear canal and auricle.
• Persistent itch in the ear.
• Mild discomfort.

History and Examination

Assess for the presence of precipitating and risk factors such as:

• Diabetes, immunosuppression, and older age.
• Exposure to water or humid climate.
• Use of hearing aid, ear plugs or cotton buds.
• Trauma to ear canal from cleaning, scratching, or instrumentation.
• Dermatoses.
• Previous topical treatments for otitis externa or otitis media.
• Previous ear surgery.
• Radiotherapy to ear.

Assess severity of symptoms:

• Signs of fungal infection on examining ear canal - whitish cotton-like strands of Candida, small black or white balls of Aspergillus.

It can be difficult to adequately visualise the tympanic membrane in people with otitis externa. However perforation can be assumed if the person:

• Can taste medication placed in the ear, or
• Can blow air out of the ear when the nose is pinched, or
• Has had a tympanostomy tube inserted in the past 12 months and there is no documentation of extrusion and closure of the tympanic membrane.

Consider necrosing otitis externa or malignancy in patients with otitis externa and the following:

• Severe pain and headache.
• Patients with diabetes.
• Granulation tissue at bone–cartilage junction of ear canal.
• Facial nerve palsy (drooping face on the side of the lesion).
• Cranial nerve impairment.

Contact on call ENT surgeon to discuss same day assessment.

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

Furuncle of the external auditory meatus

• Treat pain:
  • Treat with an analgesic and the application of local heat (for example a warm flannel).
• Treat infection if necessary:
  • Consider an oral antibiotic for patients not responding to analgesic
  • Where oral antibiotics are used they should cover staphylococci
• If abscess forms discuss with on call ENT surgeon

Acute otitis externa

• Treat pain:
  • Treat with an analgesic
• Treat with combination steroid antibiotic drops
• If severe infection consider oral antibiotics
• Keep ears clean and ear canals dry. Protect ear canals from water, soap and shampoo

Chronic otitis externa and recurrent acute otitis externa

• Exclude middle ear disease
• Reinforce self-care (see below)
• If fungal infection is suspected:
  • Prescribe a topical antifungal preparation, see formulary chapter 12.1
  • Seek specialist advice if there is inadequate response.
• If no cause is evident:
  • Prescribe a 7 day course of a topical preparation containing only a corticosteroid without antibiotic, see formulary chapter 12.1
  • If there is an adequate response, continue the corticosteroid treatment; however, 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, and evidence of fungal infection consider a trial of a topical antifungal preparation, see formulary chapter 12.1

Reinforce self-care advice, such as avoiding damage to the external ear canal and keeping the ears clean and dry.

To aid recovery and to reduce risk of future infection advise patient:

• Avoid damage to the external ear canal:
  • If earwax is a problem, the person should seek advice about removing it without damaging the ear canal.
  • Cotton buds or other objects should not be used to clean the ear canal.
• Keep the ears clean and dry by:
  • Using ear plugs when swimming, consider swim-ear after water exposure (purchase over the counter)
  • People with acute otitis externa should preferably abstain from water sports for at least 7 to 10 days.
  • Using a hair dryer (at the lowest heat setting) to dry the ear canal after hair washing, bathing, or swimming.
  • Keeping shampoo, soap, and water out of the ear when bathing and showering.
• Ensure skin conditions that are associated with the development of otitis externa are well controlled
• Consider using acidifying ear drops (ear-calm) or spray shortly before swimming, after swimming, and at bedtime. These ear drops are available over the counter.

Devon Formulary ENT chapter 12.1

Devon Formulary Analesics chapter 4.7

Referral Criteria

Discuss same day assessment with on call ENT in the following situations:

• Acute otitis externa where ear canal is occluded preventing administration of drugs or not responding to appropriate treatment in primary care.
• Necrotising otitis externa is suspected.

Consider routine referral if:

• Chronic otitis externa not responding to medical therapy.
• Suspected middle ear disease.

If severe eczema suspected consider referral to dermatology - see eczema guideline

Referral Instructions

e-Referral Service Selection

• Specialty: ENT
• Clinic Type: Ear
• Service: DRSS-Northern-Ear Nose and Throat - Devon ICB- 15N

Referral Form

DRSS Referral Form

Evidence

NICE – Otitis externa

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: November 2017

Reviewed: April 2024