Otitis externa

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Otitis externa
Straight to the point of care
Last updated: Sep 21, 2023
Table of Contents
Overview 3
Summary 3
Definition 3
Theory 5
Epidemiology 5
Aetiology 5
Pathophysiology 5
Classification 5
Case history 6
Diagnosis 8
Approach 8
History and exam 12
Risk factors 13
Investigations 14
Differentials 16
Management 20
Approach 20
Treatment algorithm overview 24
Treatment algorithm 25
Primary prevention 38
Secondary prevention 39
Patient discussions 39
Follow up 40
Monitoring 40
Complications 40
Prognosis 40
Guidelines 41
Diagnostic guidelines 41
Treatment guidelines 41
References 42
Images 49
Disclaimer 52
Otitis externa Overview
Summary
Acute otitis externa (AOE) is a diffuse inflammation of the external ear canal that is most commonly caused
by  Pseudomonas aeruginosa and Staphylococcus aureus .
Presents with rapid onset of ear pain, tenderness, itching, aural fullness, and hearing loss.
More common in children and young adults.
Fungal otitis externa is a fungal infection of the external ear caused by moulds and yeasts, which presents in
a similar way to acute bacterial otitis externa.
Necrotising otitis externa infection (also called malignant otitis externa) involves skin and soft tissue of the
external auditory canal and bone tissue of the temporal bone.
Treatment of the uncomplicated form is cleaning of the ear canal and application of topical anti-infective
agents. Oral antibiotics may be required for patients with diabetes, those who are immunocompromised,
or those who do not respond to initial topical treatment. Necrotising otitis externa is a medical emergency
requiring prompt treatment with debridement of necrotic tissue and oral or intravenous antibiotics.
Definition
AOE is defined as diffuse inflammation of the external ear canal, which may also involve the pinna or
tympanic membrane.[1] It is a form of cellulitis that involves the skin and subdermis of the external auditory
canal, with acute inflammation and variable oedema.[1] It is most commonly caused by bacterial infection
with Pseudomonas aeruginosa or Staphylococcus aureus .[1] National guidelines state that a diagnosis of
AOE requires the presence of rapid onset (generally within 48 hours) of symptoms within the past 3 weeks,
coupled with signs of ear canal inflammation.[1]
Diagram of acute otitis externa
Created by the BMJ Knowledge Centre
O
VERVIEW
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Otitis externa Overview
O
VE
RV
IE
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Otitis externa Theory
Epidemiology
Acute otitis externa (AOE) has a lifetime incidence of up to 10%.[1] [12] Each year in the US, AOE accounts
for more than 500,000 visits to ambulatory care centres or emergency departments.[12] The condition is
known to affect people of all age groups but was found to peak in the 7- to 12-year-old age group and to
decline in incidence among subjects >50 years of age.[14] In one UK study, the 12-month prevalence of
otitis externa was >1%, and it was more prevalent in women than in men up to the age of 65 years.[15] In
the same study, the incidence of otitis externa increased towards the end of the summer, especially in the
youngest age group (aged 5-19 years). It is common in warmer temperatures and high-humidity conditions
and after swimming. 
Aetiology
Acute otitis externa (AOE) is most commonly caused by bacterial infections. In North America, 98% of AOE
is caused by bacteria.[1] It is often polymicrobial, but the most common pathogens are Pseudomonas
aeruginosa (20% to 60% prevalence) and  Staphylococcus aureus (10% to 70% prevalence).[1] Other
aetiologies are idiopathic, trauma (from scratching, aggressive cleaning), chemical irritants, allergy (most
commonly to antibiotic ear drops such as neomycin), high-humidity conditions, swimming, or skin disease
(seborrhoeic dermatitis, allergic dermatitis, atopic dermatitis, psoriasis).[2] Fungal aetiology is uncommon
in primary AOE, but may be more common in chronic otitis externa, after treatment of AOE with antibiotics,
particularly topical antibiotics, in tropical countries, in humid areas, in people with diabetes, or in people who
are immunocompromised. The most common fungal pathogens are  Aspergillus species (60% to 90%) and 
Candida species (10% to 40%).[1]
Pathophysiology
The pathogenesis is multifactorial. Several risk factors can predispose to infection or initiate inflammation
and subsequently the infectious process. Intact ear canal skin and cerumen production have a protective
effect against infections. This is secondary to the fact that cerumen produces a pH in the ear canal that is
slightly acidic.[1] On the other hand, breakdown of skin integrity, insufficient cerumen production, or blockage
of the ear canal with cerumen (which promotes water retention) can predispose to infection. Skin integrity
can be injured by direct trauma, heat, and moisture or persistent water in the ear canal. Such damage is
believed to initiate the inflammatory process.[3] [13] Subsequently, oedema may result, followed by bacterial
inoculation and overgrowth.
Classification
Scott-Brown[2]
No official classification system has been published, and different authors have classified otitis externa
differently. Perhaps the most detailed classification system is as follows:
Localised otitis externa (furunculosis): localised infection in the hair follicles in the cartilaginous portion of the
external auditory canal.[3]
Diffuse otitis externa: infection is limited to the skin of the external auditory canal and concha, and possibly
the tympanic membrane.
TH
EO
RY
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Otitis externa Theory
TH
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RY
Part of a generalised skin condition: patients have other skin conditions such as seborrheic dermatitis,
allergic dermatitis, atopic dermatitis, and psoriasis.
Invasive (granulomatous/necrotising) otitis externa: necrosis of adjacent cartilage or bone of the external
auditory canal.
Others (keratosis obturans): hyperkeratosis of the external auditory canal skin, leading to corrosion of the
canal bone.
Case history
Case history #1
A 35-year-old man presents with a 2-day history of rapid-onset severe ear pain and fullness. The
patient complains of otorrhoea and mild decreased hearing. He reports that his symptoms started after
swimming. No fever is reported. On physical examination, the external ear canal is diffusely swollen and
erythematous. He has tenderness of the tragus and pain with movement of the auricle. The tympanic
membrane was partially visualised because of the swelling. The concha and the pinna look normal. Neck
examination fails to reveal any lymphadenopathy.
Other presentations
Necrotising otitis externa (also called malignant otitis externa) is a form of otitis externa that is more
common in older patients with uncontrolled diabetes or in patientsyears and older. It should be
used at the lowest effective dose for the shortest
period and treatment limited to 3 days.[62] [63]
necrotising 1st topical and systemic antibacterial therapy
plus debridement
Primary options
» ciprofloxacin: children: consult specialist for
guidance on dose; adults: 500-750 mg orally
twice daily for 6-8 weeks
--AND--
» ciprofloxacin/dexamethasone otic:
(0.3%/0.1%) children ≥6 months of age and
adults: 4 drops into the affected ear(s) twice
daily for 7-10 days
-or-
» ofloxacin otic: (0.3%) children ≥6 months
of age: 5 drops into the affected ear(s) once
daily for 7 days; adults: 10 drops into the
affected ear(s) once daily for 7 days
-or-
» ciprofloxacin otic: (0.2% solution) children
and adults: 0.5 mg (0.25 mL single-use
container) into the affected ear(s) twice daily
for 7 days; (6% suspension) children ≥6
months of age and adults: 12 mg (0.2 mL
single-use container) into external ear canal
of the affected ear(s) as a single dose
» Necrotising otitis externa is a medical
emergency.[7] All patients in this group should
have debridement of granulation tissue.
» There are no unified guidelines for the
management of necrotising otitis externa.
Some clinicians advocate starting intravenous
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Otitis externa Management
Acute
antibiotics immediately, while others start a
trial of oral ciprofloxacin in patients who are
suspected to have necrotising otitis externa not
complicated by cranial nerve involvement.[48]
Patients who do not respond to oral antibiotics
within 24-48 hours should then be started on
intravenous antibiotics. The author's usual
practice is to try oral ciprofloxacin in early
uncomplicated or suspected necrotising otitis
externa and assess the patient's response in
24-48 hours.
» Both the European Medicines Agency (EMA)
and the US Food and Drug Administration
(FDA) have issued warnings about serious,
disabling, and potentially irreversible adverse
effects associated with systemic and
inhaled fluoroquinolone antibiotics. These
adverse effects include tendonitis, tendon
rupture, arthralgia, neuropathies, and other
musculoskeletal or nervous system effects.[43]
[46] [47] The EMA now recommends that
fluoroquinolone antibiotics be restricted for use
in serious, life-threatening bacterial infections
only.[43] The FDA has also issued certain
restrictions.[45] Despite this, a systemic
fluoroquinolone is required in patients with
necrotising otitis externa.
» Oral fluoroquinolones are active against 
Pseudomonas aeruginosa , penetrate the bone
well, have excellent oral bioavailability, and have
a less significant side effect profile compared
with alternatives.[49]
» Oral ciprofloxacin has good coverage
against Pseudomonas aeruginosa and is
very commonly and successfully used in these
patients. Patients can be given oral ciprofloxacin
for 6-8 weeks.[50]
» Topical ciprofloxacin/dexamethasone,
ofloxacin, or ciprofloxacin can be used in
conjunction with systemic ciprofloxacin and are
safe to use in patients with tympanic membrane
perforation.[1] [31] Ototoxic ear drops (those that
contain aminoglycosides and alcohol) should
be avoided in patients with possible tympanic
membrane perforations.[1] [12]
» If patients fail to respond to oral ciprofloxacin
within 24-48 hours, they should be started
on intravenous antibiotics that have
antipseudomonal activity until culture and
sensitivity results are obtained.
adjunct hyperbaric oxygen
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Otitis externa Management
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Acute
Treatment recommended for SOME patients in
selected patient group
» Hyperbaric oxygenation can be used in
patients with refractory or recurrent disease,
or in patients with extensive skull base or
intracranial involvement although, in one
systematic review, no clear evidence was found
in demonstrating its efficacy when compared to
treatment with antibiotics and/or surgery.[51] [53]
[54]
adjunct pain management
Treatment recommended for SOME patients in
selected patient group
Primary options
» paracetamol: children: 10-15 mg/kg orally/
rectally every 4-6 hours when required,
maximum 75 mg/kg/day; adults: 500-1000
mg orally every 4-6 hours when required,
maximum 4000 mg/day
OR
» ibuprofen: children: 5-10 mg/kg orally every
6-8 hours when required, maximum 40 mg/
kg/day; adults: 200-400 mg orally every 4-6
hours when required, maximum 2400 mg/day
Secondary options
» paracetamol/codeine: children ≥12 years of
age: consult specialist for guidance on dose;
adults: 15-60 mg orally orally every 4-6 hours
Adults: dose refers to codeine component.
Maximum dose is based on paracetamol
component of 4000 mg/day.
OR
» oxycodone/paracetamol: adults: 5-10 mg
orally (immediate-release) every 4-6 hours
when required
Adults: dose refers to oxycodone component.
Maximum dose is based on paracetamol
component of 4000 mg/day.
» Analgesics increase patient satisfaction and
allow faster return to normal activities.
» Mild to moderate pain is usually controlled by
paracetamol or a non-steroidal anti-inflammatory
drug given alone or in combination with an opioid
(e.g., paracetamol with codeine or paracetamol
with oxycodone).[1] Analgesics should be started
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Otitis externa Management
Acute
at the initial recommended dose and adjusted
accordingly.
» Codeine is contraindicated in children younger
than 12 years, and it is not recommended
in adolescents aged 12-18 years who are
obese or have conditions such as obstructive
sleep apnoea or severe lung disease as it may
increase the risk of breathing problems.[61] It is
generally recommended only for the treatment
of acute moderate pain, which cannot be
successfully managed with other analgesics, in
children aged 12 years and older. It should be
used at the lowest effective dose for the shortest
period and treatment limited to 3 days.[62] [63]
2nd intravenous antibiotic therapy plus
debridement
Primary options
» ceftazidime: children: consult specialist for
guidance on dose; adults: 1 g intravenously
every 8-12 hours, maximum 6 g/day
Secondary options
» cefepime: 1-2 g intravenously every 12
hours
OR
» ticarcillin/clavulanic acid: children: consult
specialist for guidance on dose; adults: 3.2
g intravenously every 6-8 hours, maximum
18-24 g/day
Dose consists of 3 g ticarcillin plus 0.2 g
clavulanic acid.
OR
» piperacillin: children: consult specialist for
guidance on dose; adults: 3-4 g intravenously
every 4-6 hours, maximum 24 g/day
OR
» imipenem/cilastatin: 500-750 mg
intravenously every 12 hours
Dose refers to imipenem component.
OR
» aztreonam: 1-2 g intravenously every 8-12
hours
Tertiary options
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Otitis externa Management
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Acute
» amikacin: 7.5 mg/kg intravenously every 12
hours; or 5 mg/kg intravenously every 8 hours
OR
» tobramycin: 3 mg/kg/day intravenously
given in divided doses every 8 hours
» All patients in this group should have
debridement of granulation tissue.
» Resistance to ciprofloxacin has been
reported, but multi-drug resistance is rare.[7]
 If patients fail to respond to oral ciprofloxacin
within 24-48 hours, they should be started
on intravenous antibiotics that have anti-
pseudomonal activity until culture and sensitivity
results are obtained. Empirical intravenous
antibiotics should be started based on the
recommendation of the local infectious
disease specialist. There is no standard
recommendation, and the literature reports use
of a wide range of antibiotics both singularly
and in combination, including third- and fourth-
generation cephalosporins (ceftazidime,
cefepime), semi-synthetic penicillins (ticarcillin,
piperacillin), carbapenems (imipenem),
aztreonam, and aminoglycosides (amikacin,
tobramycin).[51] [52] One retrospective
case series and systematic literature review
concluded that ceftazidime monotherapy for 6-7
weeks was effective for treating necrotising otitis
externa.[7] In the absence of specialist infectious
disease advice, the author considers ceftazidime
a reasonable first choice, with the others as
alternative options. Suggested doses could vary
depending on factors such as the patient's renal
function and severity of infection. Amikacin and
tobramycin have serious potential side effects on
renal function and hearing and should be used
with caution and only after consultation with a
infectious disease specialist.
adjunct hyperbaric oxygen
Treatment recommended for SOME patients in
selected patient group
» Hyperbaric oxygenation can be used in
patients with refractory or recurrent disease,
or in patients with extensive skull base or
intracranial involvement although, in one
systematic review, no clear evidence was found
in demonstrating its efficacy when compared to
treatment with antibiotics and/or surgery.[51] [53]
[54]
adjunct pain management
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Otitis externa Management
Acute
Treatment recommended for SOME patients in
selected patient group
Primary options
» paracetamol: children: 10-15 mg/kg orally/
rectally every 4-6 hours when required,
maximum 75 mg/kg/day; adults: 500-1000
mg orally every 4-6 hours when required,
maximum 4000 mg/day
OR
» ibuprofen: children: 5-10 mg/kg orally every
6-8 hours when required, maximum 40 mg/
kg/day; adults: 200-400 mg orally every 4-6
hours when required, maximum 2400 mg/day
Secondary options
» paracetamol/codeine: children ≥12 years of
age: consult specialist for guidance on dose;
adults: 15-60 mg orally orally every 4-6 hours
Adults: dose refers to codeine component.
Maximum dose is based on paracetamol
component of 4000 mg/day.
OR
» oxycodone/paracetamol: adults: 5-10 mg
orally (immediate-release) every 4-6 hours
when required
Adults: dose refers to oxycodone component.
Maximum dose is based on paracetamol
component of 4000 mg/day.
» Analgesics increase patient satisfaction and
allow faster return to normal activities.
» Mild to moderate pain is usually controlled by
paracetamol or a non-steroidal anti-inflammatory
drug given alone or in combination with an opioid
(e.g., paracetamol with codeine or paracetamol
with oxycodone).[1] Analgesics should be started
at the initial recommended dose and adjusted
accordingly.
» Codeine is contraindicated in children younger
than 12 years, and it is not recommended
in adolescents aged 12-18 years who are
obese or have conditions such as obstructive
sleep apnoea or severe lung disease as it may
increase the risk of breathing problems.[61] It is
generally recommended only for the treatment
of acute moderate pain, which cannot be
successfully managed with other analgesics, in
children aged 12 years and older. It should be
M
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NAG
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Otitis externa Management
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Acute
used at the lowest effective dose for the shortest
period and treatment limited to 3 days.[62] [63]
fungal
1st topical or oral treatment
Primary options
» acetic acid/hydrocortisone otic: (2%/1%)
children ≥3 years of age and adults: 3-5
drops into the affected ear(s) three times
daily for 7-10 days
OR
» acetic acid otic: (2%) children and adults:
3-5 drops into the affected ear(s) three times
daily for 7-10 days
OR
» aluminium acetate topical: (8%) children
and adults: consult product literature for
guidance on dose
Secondary options
» clotrimazole topical: (1%) children ≥2 years
of age and adults: 3-4 drops into the affected
ear(s) three to four times daily for 7-10 days
Tertiary options
» fluconazole: children and adults: consult
specialist for guidance on dose
OR
» itraconazole: children and adults: consult
specialist for guidance on dose
» Frequent cleaning and debridement by medical
professionals is necessary. Prior to the use of
topical ear drops, the ear canal needs to be
cleaned of any debris or wax by dry swabbing or
microsuction.[18]
» Patients who have severe swelling of the ear
canal may have difficulty in using ear drops. A
wick should be inserted in the ear canal to allow
for drug delivery.
» The first line of treatment of fungal otitis
externa is still in debate.[3] Acidifying agents
such as acetic acid or aluminium acetate can be
used.[12] [55] Patients who do not respond to
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Otitis externa Management
Acute
treatment with acidifying agents can be started
on antifungal topical treatment.
» Oral antifungals may be used if caused by
candidal infection.[13] [56] Further studies are
needed to assess the benefit of oral antifungal
agents in otomycosis.[56] Dose and duration of
treatment for such an indication have not been
fully studied. Itraconazole may be used if caused
by Aspergillus infection.[16]
» Topical antibiotic treatment, which is
indicated in bacterial acute otitis externa, is
contraindicated in fungal otitis externa because
it is ineffective and may lead to further growth of
fungi.[1]
» In patients with tympanic membrane
perforation, alcoholic solvents used to dissolve
water-insoluble antifungal agents (e.g.,
clotrimazole) can also cause a burning or
stinging sensation in the ear and may be ototoxic
to the cochlea.[10] To overcome this, a wick
saturated with the antifungal can be inserted
in the ear canal to prevent the seepage of the
irritant into the middle ear. Self-medication
of clotrimazole solution with Q-tips has been
shown toimprove patient satisfaction and reduce
recurrence.[58]
» One study evaluating paper patches in
tympanic membrane perforation found that
closing the perforation with a patch and applying
Castellani’s solution topically was safe and
effective, and a faster resolution of otomycosis
was observed, accompanied by reduced
recurrence.[59]
adjunct pain management
Treatment recommended for SOME patients in
selected patient group
Primary options
» paracetamol: children: 10-15 mg/kg orally/
rectally every 4-6 hours when required,
maximum 75 mg/kg/day; adults: 500-1000
mg orally every 4-6 hours when required,
maximum 4000 mg/day
OR
» ibuprofen: children: 5-10 mg/kg orally every
6-8 hours when required, maximum 40 mg/
kg/day; adults: 200-400 mg orally every 4-6
hours when required, maximum 2400 mg/day
Secondary options
M
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NAG
EM
EN
T
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Otitis externa Management
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Acute
» paracetamol/codeine: children ≥12 years of
age: consult specialist for guidance on dose;
adults: 15-60 mg orally orally every 4-6 hours
Adults: dose refers to codeine component.
Maximum dose is based on paracetamol
component of 4000 mg/day.
OR
» oxycodone/paracetamol: adults: 5-10 mg
orally (immediate-release) every 4-6 hours
when required
Adults: dose refers to oxycodone component.
Maximum dose is based on paracetamol
component of 4000 mg/day.
» Analgesics increase patient satisfaction and
allow faster return to normal activities.
» Mild to moderate pain is usually controlled by
paracetamol or a non-steroidal anti-inflammatory
drug given alone or in combination with an opioid
(e.g., paracetamol with codeine or paracetamol
with oxycodone).[1] Analgesics should be started
at the initial recommended dose and adjusted
accordingly.
» Codeine is contraindicated in children younger
than 12 years, and it is not recommended
in adolescents aged 12-18 years who are
obese or have conditions such as obstructive
sleep apnoea or severe lung disease as it may
increase the risk of breathing problems.[61] It is
generally recommended only for the treatment
of acute moderate pain, which cannot be
successfully managed with other analgesics, in
children aged 12 years and older. It should be
used at the lowest effective dose for the shortest
period and treatment limited to 3 days.[62] [63]
2nd tympanoplasty or myringoplasty
» Typically, tympanic membrane perforation due
to fungal otitis externa is smaller in size and may
resolve with treatment. However, some cases
may require tympanoplasty or myringoplasty to
close the perforation.[10]
Primary prevention
Primary prevention of acute otitis externa is aimed at avoidance of risk factors. Prevention mainly centres
on the preservation of the natural defence mechanism of the external auditory canal, which includes skin
integrity.[1] This can be achieved by preventing the accumulation and retention of water in the ear canal.[1]
Factors that might cause water retention include blockage of the external ear canal by wax or a foreign
body, prolonged use of hearing protector devices, and swimming. There are no available randomised trials
to assess the efficacy of different strategies in prevention, but recommendations have been made in the
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Otitis externa Management
literature.[1] These include removal of obstructing cerumen, water precautions (e.g., the use of earplugs
while swimming), the use of acidifying ear drops after swimming, and avoidance of trauma to the ear
canal from cotton-tipped applicators and other objects.[19] Other suggested measures include treatment
of underlying skin conditions such as dermatitis, diabetes control, and avoidance of contact with certain
products (neomycin drops, some types of ear moulds) in patients with known allergies.[1] [16]
Secondary prevention
Advise patients to avoid the use of foreign bodies in the ear.[12] Patients with underlying skin disorders
should be treated. Advise patients to use well-fitted ear plugs while swimming, as well as to dry the ear canal
with a hair dryer and remove water from the ear by performing head-tilt manoeuvres after swimming.[12]
 Patients who have wax accumulation or who have narrow ear canals should be followed up every 6 months
to 1 year for wax cleaning. The use of acetic acid-containing ear drops after swimming also helps patients
with recurrent otitis externa in relation to swimming; however, trials are needed to confirm effectiveness.[3]
[12]
Patient discussions
During the acute phase of the treatment, patients should be instructed on how to use ear drops to ensure
adequate treatment. Patients should administer drugs into the affected ear while lying down and with
the affected ear facing upwards. The patient should put in as many drops as necessary to fill the ear
canal and then massage the ear canal and pinna to help the drops reach the medial end of the canal.
The patient is asked to remain in that position for at least 5 minutes. Patients should avoid exposing the
affected ear to water during the acute phase of the treatment.
A search for predisposing factors is helpful and sometimes necessary for effective control and prevention
of recurrence. Patients should be educated to avoid the use of cotton-tipped applicators or other foreign
objects. Patients who report ear pain and infections after swimming should use occlusive ear plugs.
Underlying dermatitis or other skin disorders should be attended to and treated with topical corticosteroids
whenever needed. A search for possible allergy to certain ear drops and/or hearing aid components
should be alluded to. The need for careful blood sugar control should be stressed in patients with
diabetes.
M
A
NAG
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Otitis externa Follow up
FO
LL
O
W
 U
P
Monitoring
Monitoring
Patients with uncomplicated forms of otitis externa do not usually require long-term monitoring. Patients
who develop recurrent episodes should be assessed for the presence of risk factors.[18]
Complications
Complications Timeframe Likelihood
contact dermatitis or other chemical-related swelling short term medium
This is secondary to a hypersensitivity reaction from the medication, most commonly neomycin. Cessation
of the offending ear drop and the use of other topical agents (e.g., ciprofloxacin/dexamethasone otic)
usually help.
cranial nerve palsy variable medium
Occurs mainly in association with necrotising otitis externa. One case series found 40% (15/37) of patients
had facial nerve palsy and 24% (9/37) had multiple cranial nerve palsies.[64]
osteomyelitis of the skull base variable low
A complication of necrotising otitis externa that requires prolonged intravenous antibiotic treatment (for
months), tends to recur, and has a significant mortality rate.
Prognosis
Patients with uncomplicated diffuse otitis externa usually respond to treatment.Between 65% and 90% of
patients have clinical resolution within 7-10 days, regardless of the agent used.[1]
The mortality rate of necrotising otitis externa has decreased over the years from 50% to 0%-15%.[49] Facial
nerve paralysis is a poor prognostic factor, and its presence indicates the need for longer treatment.[49] In
such patients, recovery of the function of the facial nerve might not occur.  Aspergillus infection and dural
enhancement of the middle cranial fossa and foramen magnum on magnestic resonance imaging are other
poor prognostic indicators in patients with necrotising otitis externa.[49]
Predisposing factors
A search for predisposing factors is helpful and sometimes necessary in patients with recurrent acute otitis
externa. Patients should be educated to avoid the use of cotton-tipped applicators or other foreign objects.
Patients who report ear pain and infections after swimming should use occlusive ear plugs. Underlying
dermatitis or other skin disorders should be attended to and treated with topical corticosteroids whenever
needed. A search for possible allergy to certain ear drops and/or hearing aid components should be
considered.
40 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
https://bestpractice.bmj.com
Otitis externa Guidelines
Diagnostic guidelines
North America
Clinical practice guideline: acute otitis externa (http://www.entnet.org/
content/clinical-practice-guidelines)
Published by: American Academy of Otolaryngology-Head and Neck
Surgery Foundation
Last published: 2014
Practice point: acute otitis externa (https://academic.oup.com/pch/
article/18/2/96/2647038)
Published by: Canadian Paediatric Society Last published: 2013 (re-
affirmed 2018)
Treatment guidelines
North America
Clinical practice guideline: acute otitis externa (http://www.entnet.org/
content/clinical-practice-guidelines)
Published by: American Academy of Otolaryngology-Head and Neck
Surgery Foundation
Last published: 2014
Practice point: acute otitis externa (https://academic.oup.com/pch/
article/18/2/96/2647038)
Published by: Canadian Paediatric Society Last published: 2013 (re-
affirmed 2018)
G
U
ID
ELIN
ES
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
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http://www.entnet.org/content/clinical-practice-guidelines
http://www.entnet.org/content/clinical-practice-guidelines
https://academic.oup.com/pch/article/18/2/96/2647038
https://academic.oup.com/pch/article/18/2/96/2647038
http://www.entnet.org/content/clinical-practice-guidelines
http://www.entnet.org/content/clinical-practice-guidelines
https://academic.oup.com/pch/article/18/2/96/2647038
https://academic.oup.com/pch/article/18/2/96/2647038
https://bestpractice.bmj.com
Otitis externa References
R
EF
ER
EN
C
ES
Key articles
• Rosenfeld RM, Schwartz SR, Cannon CR, et al. American Academy of Otolaryngology-Head and
Neck Surgery Foundation. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck
Surg. 2014 Feb;150(1 suppl):S1-24. [Erratum in: Otolaryngol Head Neck Surg. 2014 Mar;150(3):504]. 
Full text (https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599813517083) Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/24491310?tool=bestpractice.bmj.com)
• Hirsch BE. Infections of the external ear. Am J Otolaryngol. 1992 May-Jun;13(3):145-55. Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/1626615?tool=bestpractice.bmj.com)
• Jackson EA, Geer K. Acute otitis externa: rapid evidence review. Am Fam Physician.
2023 Feb;107(2):145-51. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/36791445?
tool=bestpractice.bmj.com)
• Selesnick SH. Otitis externa: management of the recalcitrant case. Am J Otology. 1994
May;15(3):408-12. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/8579150?tool=bestpractice.bmj.com)
References
1. Rosenfeld RM, Schwartz SR, Cannon CR, et al. American Academy of Otolaryngology-Head and
Neck Surgery Foundation. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck
Surg. 2014 Feb;150(1 suppl):S1-24. [Erratum in: Otolaryngol Head Neck Surg. 2014 Mar;150(3):504]. 
Full text (https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599813517083) Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/24491310?tool=bestpractice.bmj.com)
2. Browning GG. Aetiopathology of inflammatory conditions of the external and middle ear. In: Kerr AG,
ed. Scott-Brown's Otolaryngology. Oxford, UK: Butterworth-Heinemann; 1997.
3. Hirsch BE. Infections of the external ear. Am J Otolaryngol. 1992 May-Jun;13(3):145-55. Abstract
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42 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599813517083
https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599813517083
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http://www.ncbi.nlm.nih.gov/pubmed/24491310?tool=bestpractice.bmj.com
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https://bestpractice.bmj.comOtitis externa References
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bacteria and fungi causing otitis externa by a stepwise multiplex PCR. Front Cell Infect Microbiol.
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13. Selesnick SH. Otitis externa: management of the recalcitrant case. Am J Otology. 1994
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This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
43
https://www.sciencedirect.com/science/article/pii/S2213716521001661?via%3Dihub
https://www.sciencedirect.com/science/article/pii/S2213716521001661?via%3Dihub
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can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
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BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
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46 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
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This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
47
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61. US Food and Drug Administration. FDA drug safety communication: FDA requires labeling changes for
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48 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
http://www.ncbi.nlm.nih.gov/pubmed/29895341?tool=bestpractice.bmj.com
http://www.ncbi.nlm.nih.gov/pubmed/29895341?tool=bestpractice.bmj.com
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https://bestpractice.bmj.com
Otitis externa Images
Images
Figure 1: Diagram of acute otitis externa
Created by the BMJ Knowledge Centre
Figure 2: Swollen ear canal, almost completely closed due to acute otitis externa
From the collection of Dr Richard Buckingham; used with permission
IM
AG
ES
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
BMJ Best Practice topics are regularly updated and the most recent versionof the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
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https://bestpractice.bmj.com
Otitis externa Images
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Figure 3: White purulent debris can be seen at the external auditory meatus
Barry V et al. BMJ 2021;372:n714; used with permission
50 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
https://bestpractice.bmj.com
Otitis externa Images
Figure 4: The ear canal is narrowed, making it appear more slit-like, with white debris sitting on the canal wall
Barry V et al. BMJ 2021;372:n714; used with permission
IM
AG
ES
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
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Otitis externa Disclaimer
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Otitis externa Disclaimer
5-digit numerals: 10,000
4-digit numerals: 1000
numeralsin this topic.
Anthony Wright, LLM, DM, FRCS
Emeritus Professor of Otolaryngology
UCL Ear Institute, London, UK
DISCLOSURES: AW declares that he has no competing interests.
Desmond A. Nunez, MD, FRCS(ORL)
Director ENT Unit
North Bristol NHS Trust, Honorary Reader in Otolaryngology, University of Bristol, Bristol, UK
DISCLOSURES: DAN declares that he has no competing interests.with immunodeficiency.[1] [4] In
necrotising otitis externa, the infection and the inflammatory process involve not only the skin and soft
tissue of the external auditory canal but also the bone tissue of the temporal bone.[5] Early symptoms and
signs are the same as acute otitis externa (AOE), but, if left untreated, osteomyelitis of the petrous part of
the temporal bone and/or skull base could result, which may invade soft tissue, the middle ear, inner ear,
or brain.[1] [5] [6] The facial nerve may be affected, and less frequently, the glossopharyngeal and spinal
accessory nerves.[1] Necrotising otitis externa is a medical emergency.[7]  Pseudomonas aeruginosa is
implicated in most patients.[1] [7] Patients usually present with severe ear pain, otorrhoea, and fullness,
and are not responding to the conventional treatment of AOE. Depending on the stage of presentation
and the extent of invasion, patients may have facial weakness and other cranial nerve abnormalities.[1]
On physical examination, the external auditory canal is swollen, with evidence of granulation tissue
on the floor of the canal and at the bony-cartilaginous junction.[1] The diagnosis is usually made by
computed tomography or magnetic resonance imaging scans, which show presence of soft tissue and
bone destruction.[5] 
Otomycosis is a fungal infection of the external ear caused by moulds and yeasts.[8] Fungal otitis externa
accounts for approximately 9% of total otitis externa.[8] It presents in a similar way to acute bacterial
otitis externa, with ear pain, itching, aural fullness, and otorrhoea. It is common in tropical countries,
humid locations, after long-term topical antibiotic therapy, and in people with diabetes, HIV/AIDS, or other
immunocompromised states.[1] The most common fungal pathogens are Aspergillus species (60% to
90%) and  Candida species (10% to 40%).[1] Stepwise multiplex polymerase chain reaction is more
sensitive, rapid, and efficient than culture technique in differentiating bacterial otitis externa from fungal
otitis externa.[9]
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Otitis externa Theory
Tympanic membrane perforation may occur secondary to fungal otitis externa; a perforation rate of
6.75% has been reported.[8] [10] Perforation is common in otomycosis caused by  Aspergillus flavus , 
Aspergillus tubingensis , and Candida albicans .[8] The perforation of tympanic membrane due to fungal
otitis externa is smaller in size and may resolve with treatment. Some cases may require tympanoplasty.
[10] 
Physical examination reveals swollen ear canal skin and discharge. Ear discharge may be thickened and
black, gray, bluish green, yellow, or white.[1] The presence of black spores indicates  Aspergillus niger as
the causative organism.[1] [3] White filamentous hyphae can often be seen. Microscopic examination and
ear cultures can help establish the definitive diagnosis of otomycosis. Otomycosis should be suspected in
patients who fail treatment with antibacterial agents.[3] Secondary fungal infection of the external auditory
canal is well known after prolonged treatment with topical antibacterial agents.[11]
Chronic otitis externa is chronic inflammation of the ear canal skin for 3 months or longer.[12] It usually
presents with diffuse low-grade infection of months' or, at times, years' duration.[13] It is the result of
recurrent otitis externa, bacterial or fungal infections, underlying skin conditions, or otorrhoea from middle
ear infections.[3] Patients usually present with itching and scant otorrhoea but no pain.[13]
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Otitis externa Diagnosis
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Approach
Diagnosis is usually clinical, with patients presenting with rapid onset of symptoms.[3]
History and physical examination
US National guidelines state that a diagnosis of acute otitis externa (AOE) requires the presence of rapid
onset (generally within 48 hours) of symptoms within the past 3 weeks, coupled with signs of ear canal
inflammation.[1] Symptoms of ear canal inflammation include ear pain (which can be severe), itching,
and fullness, with or without decreased hearing or pain in the ear canal and temporomandibular joint
intensified by jaw motion. Signs of ear canal inflammation include tenderness over the tragus, pinna,
or both.[1] Manipulation of the ear canal is usually painful. The skin of the external auditory canal has
variable degrees of diffuse oedema, erythema, and swelling. There may be otorrhoea or cellulitis of the
pinna and adjacent skin. Otoscopy is recommended to examine the state of the tympanic membrane.
Sometimes the canal is very swollen, and this obscures the examination of the tympanic membrane.
Variable amounts of drainage and debris will be seen on otoscopic ear examination. The tympanic
membrane may be erythematous. In certain instances, cervical lymphadenopathy may be present.
Swollen ear canal, almost completely closed due to acute otitis externa
From the collection of Dr Richard Buckingham; used with permission
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Otitis externa Diagnosis
White purulent debris can be seen at the external auditory meatus
Barry V et al. BMJ 2021;372:n714; used with permission
The ear canal is narrowed, making it appear more slit-like, with white debris sitting on the canal wall
Barry V et al. BMJ 2021;372:n714; used with permission
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Otitis externa Diagnosis
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Pneumatic otoscopy and/or tympanometry
Pneumatic otoscopy and tympanometry can be performed to aid in the diagnosis.[1] Pneumatic otoscopy
will demonstrate normal tympanic membrane movement, which may be absent in patients with associated
acute otitis media. Similarly, in patients with AOE, tympanometry will be normal but will show a flat tracing
(type B) in patients with associated acute otitis media. Tympanometry may cause discomfort and pain in
patients with AOE. 
Culture and microscopy
Ear cultures are obtained mainly from patients who fail to improve with medical therapy. Cultures are
usually unnecessary on initial visit or at the time of diagnosis but can be obtained if desired.[3] The most
commonly cultured organisms are Pseudomonas and Staphylococcus species.[1] Negative cultures
are sometimes obtained in patients who are on antibiotic treatment, whether topical or systemic. Cultures
positive for fungal species are found in patients with fungal otitis externa.
Microscopy of exudate/debris from the ear canal mayreveal evidence of fungal infection. White
filamentous hyphae are seen in fungal otitis externa (otomycosis). The presence of black spores
indicates  Aspergillus niger as the causative organism.[1] [3]
Radiology
Computed tomography (CT) scans of the temporal bone with and without contrast are recommended
in patients who have persistent severe ear pain and fullness despite adequate medical therapy with
topical and oral antibiotics. This is to rule out necrotising otitis externa. Clinical features that would
suggest a need for a CT scan include pain that is disproportionate to the clinical findings and patients
with granulation tissue along the floor of the external auditory canal, especially in patients with diabetes or
those who are immunocompromised.[1] The presence of cranial neuropathies also mandates radiological
evaluation. In similar situations, and if the CT scan shows bony destruction, a magnetic resonance image
(MRI) of the internal auditory canals and skull base is obtained to better delineate the extent of infection.
Patients with diabetes mellitus and other immunocompromised conditions are particularly susceptible to
necrotising otitis externa and require radiological evaluation if there is any suspicion that they may have
the condition.
Re-evaluation in patients refractory to treatment
Patients who fail to respond to conventional treatment of AOE should be re-evaluated to rule out
fungal otitis externa, necrotising otitis externa, or, simply, non-compliance with treatment. Cultures and
microscopy can be obtained and may reveal filamentous hyphae and/or spores indicative of fungal
infection. Necrotising otitis externa should be investigated in patients who fail to respond to medical
treatment and who have persistent ear pain despite maximal therapy. Radiological evaluation with CT or
MR is indicated.
Necrotising otitis externa
Necrotising otitis externa (also called malignant otitis externa) is a form of otitis externa that is more
common in older patients with uncontrolled diabetes or in patients with immunodeficiency.[1] [4] In
necrotising otitis externa, the infection and the inflammatory process involve not only the skin and soft
tissue of the external auditory canal but also the bone tissue of the temporal bone.[5] Early symptoms
and signs are the same as AOE, but, if left untreated, osteomyelitis of the petrous part of the temporal
bone and/or skull base could result, which may invade soft tissue, the middle ear, inner ear, or brain.[1]
10 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
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Otitis externa Diagnosis
[5] [6] The facial nerve may be affected, and less frequently, the glossopharyngeal and spinal accessory
nerves.[1]
Necrotising otitis externa is a medical emergency.[7] 
Pseudomonas aeruginosa is implicated in most patients.[1] [7] Patients usually present with severe ear
pain, otorrhoea, and fullness, and are not responding to the conventional treatment of AOE. Depending on
the stage of presentation and the extent of invasion, patients may have facial weakness and other cranial
nerve abnormalities.[1] On physical examination, the external auditory canal is swollen, with evidence of
granulation tissue on the floor of the canal and at the bony-cartilaginous junction.[1]
The diagnosis is usually made by computed tomography or magnetic resonance imaging scans,
which show presence of soft tissue and bone destruction.[5] Technetium-99 or gallium scans will show
increased radioisotope uptake in the temporal bone and/or skull base, although these studies are not
routinely indicated for people with suspected necrotising otitis externa.[20] Positron emission tomography-
CT will also document increased signal in the skull base.[21] The patient’s erythrocyte sedimentation rate
(ESR) may also be raised in necrotising otitis externa.[1] [12]
One study recruited 74 UK-based clinicians and used the Delphi method to reach consensus definitions
and statements for necrotising otitis externa.[22] The following key consensus definitions and statements
have been proposed.
• Definite necrotising otitis externa is said to be present when all of the following exist: otalgia plus
otorrhoea or otalgia plus a history of otorrhoea, granulation or inflammation of the external auditory
canal, histological exclusion of malignancy in cases where this is suspected, and radiological
features consistent with necrotising otitis externa (CT and MRI findings).
• Possible necrotising otitis externa: severe infection of the external ear canal without the presence
of bony erosion of the external auditory canal on CT scan or absence of changes consistent with
necrotising otitis externa on the MRI scan and that has all of the following characteristics:
• Otalgia and otorrhoea or otalgia and a history of otorrhoea
• Granulation or inflammation of the external auditory canal
• Any of the following features: immunodeficiency, night pain, raised inflammatory markers
(erythrocyte sedimentation rate/C-reactive protein) in absence of other plausible cause, or
failure to respond to >2 weeks of topical anti-infectives and aural care.
• 'Necrotising otitis externa' is the preferred terminology over 'malignant otitis externa'.
• A case of suspected necrotising otitis externa should be primarily evaluated with a CT scan.
• Upon confirmed diagnosis of necrotising otitis externa, specialist review should be arranged.
Fungal otitis externa
Otomycosis is a fungal infection of the external ear canal caused by moulds and yeasts.[8] Fungal otitis
externa accounts for approximately 9% of total otitis externa.[8] It presents in a similar way to acute
bacterial otitis externa, with ear pain, itching, aural fullness, and otorrhoea. It is common in tropical
countries, humid locations, after long-term topical antibiotic therapy, and in people with diabetes, HIV/
AIDS, or other immunocompromised states.[1] The most common fungal pathogens are Aspergillus 
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Otitis externa Diagnosis
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species (60% to 90%) and Candida  species (10% to 40%).[1] Stepwise multiplex polymerase chain
reaction is more sensitive, rapid, and efficient than culture technique in differentiating bacterial otitis
externa from fungal otitis externa.[9]
Tympanic membrane perforation may occur secondary to fungal otitis externa; a perforation rate of
6.75% has been reported.[8] [10] Perforation is common in otomycosis caused by  Aspergillus flavus , 
Aspergillus tubingensis , and Candida albicans .[8] The perforation of tympanic membrane due to fungal
otitis externa is smaller in size and may resolve with treatment. Some cases may require tympanoplasty.
[10] 
Physical examination reveals swollen ear canal skin and discharge. Ear discharge may be thickened and
black, gray, bluish green, yellow, or white.[1] The presence of black spores indicates Aspergillus niger as
the causative organism.[1] [3] White filamentous hyphae can often be seen. Microscopic examination and
ear cultures can help establish the definitive diagnosis of otomycosis. Otomycosis should be suspected in
patients who fail treatment with antibacterial agents.[3] Secondary fungal infection of the external auditory
canal is well known after prolonged treatment with topical antibacterialagents.[11] 
History and exam
Key diagnostic factors
presence of risk factors (common)
• Risk factors for acute otitis externa include external auditory canal obstruction, high environmental
humidity, warmer environmental temperatures, swimming, local trauma, allergy, skin disease, diabetes,
immunocompromised state, and prolonged used of topical antibacterial agents.
ear pain (common)
• Patients with acute otitis externa typically present with an acute onset of ear pain.[1]
tenderness over the tragus, pinna, or both (common)
• Signs of ear canal inflammation include tenderness over the tragus, pinna, or both.[1] Manipulation of
the ear canal is usually painful.
ear canal swelling and erythema (common)
• On physical examination, the skin of the external auditory canal appears erythematous and swollen.[1]
granulation tissue in the ear canal (necrotising otitis externa) (uncommon)
• A key factor in necrotising otitis externa.[1]
Other diagnostic factors
otorrhoea (common)
• Discharge from the external auditory canal may be present in acute otitis externa.[1]
aural fullness (common)
• Patients may complain of a fullness in the ears.[1]
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Otitis externa Diagnosis
itching (common)
• Patients may complain of itchiness in the ears.[1] Scratching with matchsticks or cotton buds often
precedes infection.
decreased hearing (common)
• In the absence of concomitant acute otitis media, hearing loss is usually secondary to blockage of the
ear canal by swelling and/or debris.[1]
pain intensified by jaw motion (common)
• There may be pain in the ear canal and temporomandibular joint intensified by jaw motion.[1]
erythematous tympanic membrane (common)
• In addition to swelling in the external auditory canal, the tympanic membrane may appear
erythematous, which can make exclusion and differentiation from acute otitis media difficult.[1]
cellulitis of the pinna and adjacent skin (common)
• There may be cellulitis of the pinna and adjacent skin.[1]
Risk factors
Strong
external auditory canal obstruction
• Obstruction of the external auditory canal by cerumen may promote retention of water and debris,
which, in turn, may disrupt the integrity of the skin of the external auditory canal.[16] This in itself, or
in the presence of additional risk factors, can cause infection. External auditory canal obstruction can
also be caused by foreign bodies, a narrow ear canal, bony exostosis, or sebaceous cysts.  
high environmental humidity
• Otitis externa is more common in areas with warmer weather or high humidity, or with increased
water exposure from swimming.[1] This in itself may be enough to affect skin integrity and cause
infection.[3] 
warmer environmental temperatures
• Otitits externa is more common in areas with warmer weather or high humidity.[1] This in itself may be
enough to affect skin integrity and cause infection.[3] Sweating may also increase moisture in the ear
canal.[12]
swimming
• The incidence is increased fivefold in swimmers, which is why the condition is also called 'swimmer's
ear'.[14] It is also the most common otologic disorder in divers, affecting almost half of all active divers
at least once.[17] The causative organisms have also been found in hot water tubs.[18]
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Otitis externa Diagnosis
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local trauma
• Trauma disrupts the integrity of the external auditory canal skin and will initiate the process of
inflammation.[3] [13] Local trauma can result from manual wax cleaning, use of irrigation to clean wax,
and the use of foreign objects in the ear such as cotton-tipped applicators.
allergy
• Most commonly from antibiotic ear drops such as neomycin.[2]
skin disease
• Includes seborrhoeic dermatitis, allergic dermatitis, atopic dermatitis, and psoriasis.[2]
diabetes
• Patients with diabetes are at higher risk for severe otitis externa; a modified treatment regimen is
required for treating these patients.[1] [12][18]
immunocompromised
• Patients who have received irradiation or those who are immunocompromised are at higher risk for
severe otitis externa; a modified treatment regimen is required for treating these patients.[1] [12] [18]
prolonged use of topical antibacterial agents
• These agents may inhibit the normal flora after prolonged use in the external auditory canal, and their
use is a risk factor for fungal otitis externa.[11]
Weak
chemical irritants
• Chemicals contained in ear medications, ear plugs, shampoo, and hair products can irritate and
inflame the skin of the ear and make it susceptible to infection.[18]
Investigations
1st test to order
Test Result
pneumatic otoscopy
• Normal in patients with acute otitis externa (AOE) alone, but
abnormal in patients with otitis media alone or in combination with
AOE.
normal
tympanometry
• Normal in patients with acute otitis externa (AOE) alone, but
abnormal in patients with otitis media alone or in combination with
AOE. May cause discomfort in patients with AOE.
normal
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Otitis externa Diagnosis
Other tests to consider
Test Result
ear culture
• Ear cultures are recommended in patients who fail to respond to
conventional therapy, and results will direct the choice of systemic
antibiotics.[3]
growth of the causative
pathogen
microscopy of exudate/debris from ear canal
• White filamentous hyphae are seen on microscopic examination
of exudate/debris from the ear canal in fungal otitis externa
(otomycosis).The presence of black spores indicates  Aspergillus
niger as the causative organism in fungal otitis externa
(otomycosis).[1] [3]
white filamentous hyphae
and/or black spores in
otomycosis
CT scan of the temporal bone with intravenous contrast
• CT scans are recommended in patients who have persistent
severe ear pain and fullness despite adequate medical therapy
with topical and oral antibiotics. This is to rule out necrotising
otitis externa. Clinical features that would suggest a need for a CT
scan include pain that is disproportionate to the clinical findings
and patients with granulation tissue along the floor of the external
auditory canal, especially in patients with diabetes or those who are
immunocompromised.[1]
bony erosion and invasion
of petrous apex or skull
base
MRI of the brain and internal auditory canals (with and without
gadolinium)
• Ordered in addition to CT scan when necrotising otitis externa is
suspected, especially in patients with diabetes or those who are
immunocompromised.
soft tissue outside the
confines of the external
auditory canal
erythrocyte sedimentation rate (ESR)
• The patient’s ESR may be raised in necrotising otitis externa.[1] [12]
raised in necrotising otitis
externa
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Otitis externa Diagnosis
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Differentials
Condition Differentiating signs /
symptoms
Differentiating tests
Acute otitis media • Acute otitis media and acute
otitis externa (AOE) present
with ear pain. Hearing loss
may be present in both.
The tympanic membrane
may be erythematous
in AOE, making it more
challenging to rule out either
an associated acute otitis
media or acute otitis media
alone.
• Pneumatic otoscopy shows
mobility of the tympanic
membrane in AOE and
limited or absent mobility in
acute otitis media.[1]
• Tympanometry will reveal a
normal peaked curve in AOE
but a flat (type B) curve in
acute otitis media.[1]
Furunculosis • Furunculosis is sometimes
referred to as 'localised
acute otitis externa
(AOE)'.[1] It usually
represents a localised
infected hair follicle in the
cartilaginous portion of
the ear canal.[23] The
presenting symptoms are
similar to those of diffuse
AOE. It presents with otalgia
and tenderness.
• On physical examination,
the infection is confined to
the cartilaginous portion
of the ear canal.[3] The
bony (medial) portion of the
external auditory canal is
usually normal.
• No differentiating tests.
Contact dermatitis of the
ear canal
• This is an allergic reaction
to antigens that could be
present in hearing aid
material, cosmetics, and
other topical otic solutions.
Patients usually give a
history of prior use of topical
solutions.
• Among the topical solutions,
neomycin is the most
commonly implicated
agent.[1] Patients with
allergies to otic topical
solutions usually present
with erythema and oedema
that extend into the conchal
bowl.
• No differentiating tests.
Viral infections of the
external ear
• Viral infections of the
external ear, caused by
• No differentiating tests.
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Otitis externa Diagnosis
Condition Differentiating signs /
symptoms
Differentiating tests
varicella, measles, or herpes
virus, are rare but important
differentials of acute otitis
externa.[1]
• Severe otalgia, facial
paralysis or paresis, taste
disturbance on the anterior
two-thirds of the tongue, and
decreased lacrimation on
the affected side.[1] Physical
examination may reveal
erythema and/or vesicles in
the ear canal and auricle.[3]
Chronic otitis externa • Chronic otitis externa is
chronic inflammation of the
ear canal skin for 3 months
or longer.[12] It usually
presents with diffuse low-
grade infection of months' or,
at times, years' duration.[13]
It is the result of recurrent
otitis externa, bacterial or
fungal infections, underlying
skin conditions, or otorrhoea
from middle ear infections.[3]
Patients usually present with
itching and scant otorrhoea
but no pain.[13]
• Physical examination of the
ear varies, depending on the
severity of the infection, and
can range from dry skin to
granulation tissue.[13]
• No differentiating tests.
Cancer of the external
auditory canal
• Recalcitrant to usual medical
therapy.
• Biopsy of the external
auditory canal.[1]
Cholesteatoma • Consider particularly in
recalcitrant disease not
responding to medical
therapy. Otoscopy typically
shows crust or keratin in
the attic (upper part of
the middle ear), the pars
flaccida, or the pars tensa
(usually posterior superior
aspect), with or without a
perforation of the tympanic
membrane.
• CT can help with confirming
the diagnosis, assessing
disease extension, and
treatment planning.
Ear canal cholesteatoma • Rare disease of the external
auditory canal. It usually
presents with ear discharge,
focal erosion, and keratin
• CT may reveal a localised
cholesteatoma, with or
without extension into the
middle ear or mastoid cavity.
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17
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Otitis externa Diagnosis
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Condition Differentiating signs /
symptoms
Differentiating tests
accumulation in the bony ear
canal.[24]
Eczema (atopic
dermatitis)
• Eczema is an inflammatory
skin condition characterised
by dry, pruritic skin with a
chronic relapsing course. It
can affect all age groups,
but it is most commonly
diagnosed before 5 years
of age and affects 10% to
20% of children.[25] Patients
often have a personal
or family history of other
atopic diseases such as
asthma or allergic rhinitis.
Food allergies may occur
at increased rates in this
population. Eczema can
be described as acute or
chronic. Acute eczema is
used to describe a flare-up of
symptoms. Chronic is used
to describe the condition
when the patient develops
signs of chronic inflammation
(e.g., lichenification).
• No differentiating tests;
diagnosis of eczema is
primarily clinical.
Seborrhoea (seborrhoeic
dermatitis)
• Seborrhoeic dermatitis is a
chronic inflammatory skin
disorder characterised by
erythematous and greasy
scaly patches. Patches are
red, inflamed, and pruritic
with micaceous scale.
Circumscribed patches are
found on the scalp, glabella,
nasolabial fold, posterior
auricular skin, and anterior
chest. Variable course that
seldom completely subsides.
An infant form (cradle cap)
usually resolves within the
first few months of life. Tends
to flare with stress.[26] The
adult scalp form is commonly
termed dandruff or pityriasis
capitis.
• No differentiating tests,
diagnosis of seborrhoea is
primarily clinical.
Chronic suppurative
otitis media
• Chronic suppurative otitis
media is suggested by
chronic or intermittent
otorrhoea over a period of
weeks to months, especially
• No differentiating tests.
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Otitis externa Diagnosis
Condition Differentiating signs /
symptoms
Differentiating tests
with a non-intact tympanic
membrane.[12]
Otitis media with effusion • Otitis media with effusion
(OME; also known as glue
ear) typically presents with
hearing loss, ear pressure or
discomfort, or ear blockage
without symptoms of acute
infection. Signs/symptoms
include middle ear effusion,
no sign of acute infection,
aural fullness or pressure,
hearing loss, failed hearing
screen, speech delay, signs
of ear discomfort, and low
progress in an educational
setting.
• Pneumatic otoscopy:
decreased movement of
tympanic membrane on air
insufflation when there is
effusion in the middle ear.
• Tympanometry: typically
a flat (type B) curve (low
compliance) if OME is
present; a type C curve,
which suggests negative
pressure, may be seen.
• Audiology: may show
moderate conductive hearing
loss.
Temporomandibular
disorders
• Temporomandibular
disorders (TMDs) comprise
several painful disorders
involving the mandibular
joint and muscles of
mastication.[27] [28]
 TMDs typically present
with four characteristic
features:temporomandibular
joint pain, noise in the
joint, masticatory muscle
tenderness, and limited
mandibular movement.
TMDs are a common cause
of referred otalgia.[1]
• No differentiating tests;
diagnosis of TMDs is
primarily clinical.
D
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Otitis externa Management
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Approach
The main goals of treatment are to control pain, cure infection, and prevent recurrence. Treatment is usually
given as for bacterial infection initially. Treatment for fungal infection is given if there are visual signs of fungal
growth, or if presumptive bacterial treatment has failed. Prior to the use of topical ear drops, the ear canal
needs to be cleaned of any debris or wax by dry swabbing or microsuction.[18] This allows the status of the
tympanic membrane to be checked as well as enhancing skin penetration of the topical solution.[18] When
using ear drops, advise the patient to apply the drops lying down with the affected ear upwards and wait for
5-10 minutes before getting up.
Presumed bacterial infection: initial treatment in otherwise
healthy people
In people who do not have other medical issues such as diabetes, HIV/AIDS, other immunocompromised
states, or a history of radiotherapy, and who do not have signs of fungal infection or necrotising otitis
externa, initial presumptive treatment is with topical antibacterial ear drops, plus analgesia.[1] Prior to
the use of topical ear drops, the ear canal needs to be cleaned of any debris or wax by dry swabbing or
microsuction.[18] Patients who have severe swelling of the ear canal may have difficulty using ear drops.
A wick should be inserted in the ear canal to allow for drug delivery. 
Several ear drops are available for first-line treatment. Studies have failed to demonstrate difference in
outcome with different products.[1] [29] The choice of the ear drop should be based on patient preference,
and the clinician's experience, taking into account efficacy, low incidence of adverse events, likelihood of
adherence to therapy, and cost.[1]
One of the early treatments consisted of topical acetic acid, and a 2007 study confirmed trichloroacetic
acid as an effective and safe treatment for acute otitis externa.[30]
Currently, topical antibiotic solutions are more commonly used in acute otitis externa (AOE).[31] [32]
 Neomycin- and polymyxin B-containing solutions were one of the first antibiotic ear drops to be used
and demonstrated efficacy against pathogens causing AOE.[33] The addition of a corticosteroid to
such preparations was found to hasten symptomatic relief.[34] However, solutions containing neomycin,
polymyxin-B, or hydrocortisone are to be avoided in patients with tympanic membrane perforation due to
potential ototoxicity.[1] [12] [31]
Fluoroquinolone-containing (ciprofloxacin and ofloxacin) agents have become available and are effective
against both gram-negative and gram-positive pathogens that are common in otitis externa.[31] [35] [36]
 In one systematic review, a combined ciprofloxacin/dexamethasone preparation was found to be safe and
effective in patients with AOE.[37] One meta-analysis found that fluoroquinolone-containing ear drops are
superior to combination drugs not containing a fluoroquinolone.[38] Hypersensitivity to fluoroquinolone ear
drops is not very common, and they can be used in patients with tympanic membrane perforations.[1] [12]
[31] However, one retrospective cohort study found that the use of fluoroquinolone-containing ear drops
to treat AOE is associated with a previously unreported increased risk of developing tympanic membrane
perforation, although this has not yet changed clinical practice.[39]
In one randomised clinical study of patients with AOE, it was found that a combined ciprofloxacin/
dexamethasone preparation resulted in less time to cure when compared with polymyxin B/neomycin/
hydrocortisone otic suspension.[40] Another randomised clinical trial found ciprofloxacin/dexamethasone
otic to be equal in effectiveness to topical neomycin/polymyxin B/hydrocortisone administered with
20 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
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Otitis externa Management
systemic amoxicillin in the treatment of AOE.[41] These observations have produced a shift in treatment
preference towards the fluoroquinolone-containing ear drops.[31] However, the older topical solutions are
still very commonly used and may be more affordable.
Care should be exercised in patients who are known, or suspected, to have a tympanic membrane
perforation, including a tympanostomy tube, to avoid ototoxic ear drops (those that contain
aminoglycosides and alcohol).[1] [12] In that situation, ofloxacin or ciprofloxacin/dexamethasone can be
used.[1]
Symptoms of diffuse AOE should improve within 48-72 hours of starting topical therapy. For patients who
fail to show a response within this time frame, reassessment is recommended to confirm the diagnosis
of diffuse AOE and exclude other conditions. Reasons for lack of response to treatment for diffuse AOE
include obstruction of the ear canal, poor adherence to treatment, incorrect diagnosis, and microbiological
factors. If any obstruction cannot be addressed with removal of debris and/or wick placement, then
systemic antibiotics may be needed. A culture of the external auditory canal can identify fungi, resistant
bacteria, or unusual causes of infection that would need targeted topical or systemic therapy.[1] Culture
and sensitivity may help to guide antibiotic therapy in patients refractory to initial treatment. If symptoms
persist despite initial treatment, then alternative diagnoses such as skin disorders, foreign bodies,
perforated tympanic membrane, or middle ear disease should be considered.
Patients with other medical problems
Patients with diabetes, those who have received irradiation, or those who are immunocompromised
(e.g., with HIV/AIDS, or patients receiving chemotherapy) are at higher risk for rapid escalation from
mild to severe manifestations of AOE or for developing necrotising otitis externa.[1] [12][42] Treatment
approach in these patients is different and requires the use of systemic antibiotics in addition to the
treatment outlined under the general approach above.[1] [13] In addition, irrigation should not be used
to remove debris from these patients' ear canals, as this may predispose the patients to necrotising
otitis externa.[1] Patients with concurrent middle ear disease, such as acute otitis media or a tympanic
membrane perforation, may also require systemic antibiotics.[1]
Oral ciprofloxacin is an effective medication; however, it is not generally recommended in children.[13]
In addition, in November 2018, the European Medicines Agency (EMA) completed a review of
serious, disabling, and potentially irreversible adverse effects associated with systemic and inhaled
fluoroquinolone antibiotics. These adverse effects include tendonitis, tendon rupture, arthralgia,
neuropathies, and other musculoskeletal or nervous system effects. As a consequence of this review, the
EMA now recommends that fluoroquinolone antibiotics be restricted for use in serious, life-threatening
bacterial infections only. Furthermore, they recommend that fluoroquinolones should not be used for
mild to moderate infections,unless other appropriate antibiotics for the specific infection cannot be
used, and should not be used in non-severe, non-bacterial, or self-limiting infections. Patients who are
older, have renal impairment, or have had a solid organ transplant, as well as those being treated with
a corticosteroid, are at a higher risk of tendon damage. Co-administration of a fluoroquinolone and a
corticosteroid should be avoided.[43] The UK-based Medicines and Healthcare products Regulatory
Agency support these recommendations.[44] The US Food and Drug Administration (FDA) issued a
similar safety communication, restricting the use of fluoroquinolones in acute sinusitis, acute bronchitis,
and uncomplicated urinary tract infections.[45] In addition to these restrictions, the FDA has issued
warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health
adverse effects in patients taking fluoroquinolones.[46] [47]
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Otitis externa Management
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Despite this, a systemic fluoroquinolone is usually required in patients with non-necrotising otitis externa
who have comorbidities (diabetes or immunocompromised state), as they are at higher risk for rapid
escalation from mild to severe manifestations of AOE, or for developing necrotising otitis externa.[1] [12]
[42] Advice should be sought from an infectious diseases specialist to guide selection of antibiotic and
decide on whether a fluoroquinolone is warranted here. In these patients, cultures may be taken to assist
in the proper choice of oral antibiotics. Oral amoxicillin/clavulanate or amoxicillin are other options to
cover  Staphylococcus aureus if Pseudomonas aeruginosa is unlikely, or while awaiting results, or if
cultures are negative.
Necrotising otitis externa
Necrotising otitis externa is an aggressive infection that mainly affects older people with diabetes or
those who are immunocompromised, and is a medical emergency.[7]  Pseudomonas aeruginosa is
implicated in most patients.[1] [7] Staphylococci may also be implicated, including methicillin-resistant 
Staphylococcus aureus .[1] There are no unified guidelines for the management of necrotising otitis
externa. Some clinicians advocate starting intravenous antibiotics immediately, while others start a trial
of oral ciprofloxacin in patients who are suspected to have necrotising otitis externa not complicated by
cranial nerve involvement.[48] Patients who do not respond to oral antibiotics within 24-48 hours should
then be started on intravenous antibiotics. The author's usual practice is to try oral ciprofloxacin in early
uncomplicated or suspected necrotising otitis externa and assess the patient's response in 24-48 hours.
All patients in this group should have debridement of granulation tissue. Oral fluoroquinolones are active
against  Pseudomonas aeruginosa , penetrate the bone well, have excellent oral bioavailability, and have
a less significant side effect profile compared with alternatives.[49] Oral ciprofloxacin has good coverage
against Pseudomonas aeruginosa and is very commonly and successfully used in these patients.
Patients can be given oral ciprofloxacin for 6-8 weeks.[50]
Resistance to ciprofloxacin has been reported, but multi-drug resistance is rare.[7] If patients fail to
respond to oral ciprofloxacin within 24-48 hours, they should be started on intravenous antibiotics that
have anti-pseudomonal activity until culture and sensitivity results are obtained. Empirical intravenous
antibiotics should be started based on the recommendation of the local infectious disease specialist.
There is no standard recommendation, and the literature reports use of a wide range of antibiotics
both singularly and in combination, including third- and fourth-generation cephalosporins (ceftazidime,
cefepime), semi-synthetic penicillins (ticarcillin, piperacillin), carbapenems (imipenem/cilastatin),
aztreonam, and aminoglycosides (amikacin, tobramycin).[51] [52] One retrospective case series and
systematic literature review concluded that ceftazidime monotherapy for 6-7 weeks was effective for
treating necrotising otitis externa.[7] In the absence of specialist infectious disease advice, the author
considers ceftazidime a reasonable first choice, with the others as alternative options.
Hyperbaric oxygenation can be used in patients with refractory or recurrent disease, or in patients with
extensive skull base or intracranial involvement.[51] [53] However, one systematic review about the use
of hyperbaric oxygen as an adjuvant treatment for necrotising otitis externa failed to show clear evidence
demonstrating its efficacy when compared with treatment with antibiotics and/or surgery.[54]
Fungal
Acute fungal otitis externa is more common in tropical countries, humid locations, after long-term topical
antibiotic therapy, and in people with diabetes, HIV/AIDS, or other immunocompromised states.[1] The
most common fungal pathogens are  Aspergillus species (60% to 90%) and  Candida species (10% to
40%).[1]
22 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
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Otitis externa Management
The first line of treatment of fungal otitis externa is still in debate.[3] Acidifying agents such as acetic
acid or aluminium acetate can be used.[12] [55] Patients who do not respond to treatment with acidifying
agents can be started on antifungal topical treatment. If Candida is cultured, an oral antifungal (e.g.,
fluconazole, itraconazole) may help.[13] [56] Further studies are needed to assess the benefit of oral
antifungal agents in otomycosis.[56] Frequent cleaning and debridement by medical professionals is
also an essential part of treatment. AOE secondary to  Aspergillus infections may require the use of oral
itraconazole.[16] If fungal otitis externa is refractory to treatment and there is progression of disease,
consider fungal necrotising otitis externa.[57] Topical antibiotic treatment, which is indicated in bacterial
AOE, is contraindicated in fungal otitis externa because it is ineffective and may lead to further growth of
fungi.[1]
Care should be exercised in patients who are known, or suspected, to have a tympanic membrane
perforation, including a tympanostomy tube, to avoid ototoxic ear drops.[1] [12] Alcoholic solvents used
to dissolve water-insoluble antifungal agents (e.g., clotrimazole) can also cause a burning or stinging
sensation in the ear and may be ototoxic to the cochlea.[10] To overcome this, a wick saturated with the
antifungal can be inserted in the ear canal to prevent the seepage of the irritant into the middle ear. Self-
medication of clotrimazole solution with Q-tips has been shown to improve patient satisfaction and reduce
recurrence.[58] One study evaluating paper patches in tympanic membrane perforation found that closing
the perforation with a patch and applying Castellani’s solution topically was safe and effective, and a
faster resolution of otomycosis was observed, accompanied by reduced recurrence.[59]
Severe swelling of the ear canal
Patients who have severe swelling of the ear canal may have difficulty in using the ear drops. A
wick should be inserted in the ear canal to allow for drug delivery. Such wicks are often made of
dry, compressedMerocel® in a form that facilitates insertion into the swollen ear canal. Subsequent
application of topical antibiotic solution expands the wick to fill the canal and make contact with the
swollen tissue, thus enhancing penetration of the medication to the inflamed tissue. The wick can
then either be removed or replaced after 48 hours if swelling persists. One study of three different
packing materials in the treatment of severe AOE found that ear wick and ribbon gauze were superior to
biodegradable synthetic polyurethane foam for relieving signs and symptoms, especially on the third day
of treatment.[60] In some patients, cleaning of debris and/or placement of a wick may not be possible;
these patients may require systemic antibiotics.[1]
Analgesics
Analgesics increase patient satisfaction and allow faster return to normal activities. Mild to moderate
pain is usually controlled by paracetamol or a non-steroidal anti-inflammatory drug given alone or in
combination with an opioid.[1] Analgesics should be started at the initial recommended dose and adjusted
accordingly. Codeine is contraindicated in children younger than 12 years, and it is not recommended in
adolescents aged 12-18 years who are obese or have conditions such as obstructive sleep apnoea or
severe lung disease as it may increase the risk of breathing problems.[61] It is generally recommended
only for the treatment of acute moderate pain, which cannot be successfully managed with other
analgesics, in children aged 12 years and older. It should be used at the lowest effective dose for the
shortest period and treatment limited to 3 days.[62] [63]
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Otitis externa Management
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Treatment algorithm overview
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Acute ( summary )
bacterial
initial treatment in
otherwise healthy people
1st antibacterial otic drops
adjunct pain management
refractory to initial
treatment, or with
diabetes or with
immunodeficiency
1st topical and systemic antibacterial therapy
adjunct pain management
necrotising 1st topical and systemic antibacterial therapy
plus debridement
adjunct hyperbaric oxygen
adjunct pain management
2nd intravenous antibiotic therapy plus
debridement
adjunct hyperbaric oxygen
adjunct pain management
fungal
1st topical or oral treatment
adjunct pain management
2nd tympanoplasty or myringoplasty
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Otitis externa Management
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Acute
bacterial
initial treatment in
otherwise healthy people
1st antibacterial otic drops
Primary options
» ciprofloxacin/dexamethasone otic:
(0.3%/0.1%) children ≥6 months of age and
adults: 4 drops into the affected ear(s) twice
daily for 7-10 days
OR
» ofloxacin otic: (0.3%) children ≥6 months
of age: 5 drops into the affected ear(s) once
daily for 7 days; adults: 10 drops into the
affected ear(s) once daily for 7 days
OR
» ciprofloxacin otic: (0.2% solution) children
and adults: 0.5 mg (0.25 mL single-use
container) into the affected ear(s) twice daily
for 7 days; (6% suspension) children ≥6
months of age and adults: 12 mg (0.2 mL
single-use container) into external ear canal
of the affected ear(s) as a single dose
Secondary options
» ciprofloxacin/hydrocortisone otic: (0.2%/1%)
children ≥1 year of age and adults: 3 drops
into the affected ear(s) twice daily for 7-10
days
OR
» neomycin/polymyxin B/hydrocortisone otic:
children: 3 drops into the affected ear(s) three
to four times daily for 7-10 days; adults: 4
drops into the affected ear(s) three to times
daily for 7-10 days
» In people who do not have other medical
issues such as diabetes, HIV/AIDS, other
immunocompromised states, or a history of
radiotherapy, and who do not have signs of
fungal infection or necrotising otitis externa,
initial presumptive treatment is with topical
antibacterial ear drops, plus analgesia.[1]
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Otitis externa Management
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Acute
» Prior to the use of topical ear drops, the ear
canal needs to be cleaned of any debris or wax
by dry swabbing or microsuction.[18]
» Patients who have severe swelling of the ear
canal may have difficulty in using ear drops. A
wick should be inserted in the ear canal to allow
for drug delivery.
» Ototoxic ear drops (those that contain
aminoglycosides and alcohol) should be
avoided in patients with possible tympanic
membrane perforations, including those with a
tympanostomy tube.[1] [12]
» Ciprofloxacin/dexamethasone, ofloxacin,
and ciprofloxacin can be used in patients with
perforated tympanic membranes.[1] [31]
adjunct pain management
Treatment recommended for SOME patients in
selected patient group
Primary options
» paracetamol: children: 10-15 mg/kg orally/
rectally every 4-6 hours when required,
maximum 75 mg/kg/day; adults: 500-1000
mg orally every 4-6 hours when required,
maximum 4000 mg/day
OR
» ibuprofen: children: 5-10 mg/kg orally every
6-8 hours when required, maximum 40 mg/
kg/day; adults: 200-400 mg orally every 4-6
hours when required, maximum 2400 mg/day
Secondary options
» paracetamol/codeine: children ≥12 years of
age: consult specialist for guidance on dose;
adults: 15-60 mg orally orally every 4-6 hours
Adults: dose refers to codeine component.
Maximum dose is based on paracetamol
component of 4000 mg/day.
OR
» oxycodone/paracetamol: adults: 5-10 mg
orally (immediate-release) every 4-6 hours
when required
Adults: dose refers to oxycodone component.
Maximum dose is based on paracetamol
component of 4000 mg/day.
» Analgesics increase patient satisfaction and
allow faster return to normal activities.
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Otitis externa Management
Acute
» Mild to moderate pain is usually controlled by
paracetamol or a non-steroidal anti-inflammatory
drug given alone or in combination with an opioid
(e.g., paracetamol with codeine or paracetamol
with oxycodone).[1] Analgesics should be started
at the initial recommended dose and adjusted
accordingly.
» Codeine is contraindicatedin children younger
than 12 years, and it is not recommended
in adolescents aged 12-18 years who are
obese or have conditions such as obstructive
sleep apnoea or severe lung disease as it may
increase the risk of breathing problems.[61] It is
generally recommended only for the treatment
of acute moderate pain, which cannot be
successfully managed with other analgesics, in
children aged 12 years and older. It should be
used at the lowest effective dose for the shortest
period and treatment limited to 3 days.[62] [63]
refractory to initial
treatment, or with
diabetes or with
immunodeficiency
1st topical and systemic antibacterial therapy
Primary options
» ciprofloxacin: children: consult specialist for
guidance on dose; adults: 500-750 mg orally
twice daily
-or-
» amoxicillin: children ≤3 months of age: 30
mg/kg/day orally given in 2 divided doses;
children >3 months of age: 20-40 mg/kg/day
orally given in 3 divided doses (maximum 500
mg/dose), or 25-45 mg/kg/day orally given
in 2 divided doses (maximum 875 mg/dose);
adults: 250-500 mg orally three times daily, or
500-875 mg orally twice daily
Higher doses may be required in some
patients; consult a specialist or local protocols
for further guidance.
-or-
» amoxicillin/clavulanate: children ≤3 months
of age: 30 mg/kg/day orally given in 2 divided
doses; children >3 months of age: 20-40
mg/kg/day orally given in 3 divided doses
(maximum 500 mg/dose), or 25-45 mg/kg/day
orally given in 2 divided doses (maximum 875
mg/dose); adults: 250-500 mg orally three
times daily, or 500-875 mg orally twice daily
Dose refers to amoxicillin component. Higher
doses may be required in some patients;
consult a specialist or local protocols for
further guidance.
--AND--
» ciprofloxacin/dexamethasone otic:
(0.3%/0.1%) children ≥6 months of age and
adults: 4 drops into the affected ear(s) twice
daily
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Otitis externa Management
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Acute
-or-
» ofloxacin otic: (0.3%) children ≥6 months
of age: 5 drops into the affected ear(s) once
daily; adults: 10 drops into the affected ear(s)
once daily
-or-
» ciprofloxacin otic: (0.2% solution) children
and adults: 0.5 mg (0.25 mL single-use
container) into the affected ear(s) twice daily
» Patients with diabetes or those who are
immunocompromised benefit from the addition
of oral antibiotics.[1] In addition, patients who
failed to respond to 48-72 hours of topical
treatment, despite a correct diagnosis of
diffuse acute otitis externa (AOE) and good
adherence with treatment, may also benefit
from systemic antibiotics, particularly if any
ear canal obstruction cannot be addressed.[1]
Culture and sensitivity may help to guide
antibiotic therapy in patients refractory to initial
treatment. Patients with concurrent middle
ear disease, such as acute otitis media or a
tympanic membrane perforation, may also
require systemic antibiotics.[1]
» Both the European Medicines Agency (EMA)
and the US Food and Drug Administration
(FDA) have issued warnings about serious,
disabling, and potentially irreversible adverse
effects associated with systemic and
inhaled fluoroquinolone antibiotics. These
adverse effects include tendonitis, tendon
rupture, arthralgia, neuropathies, and other
musculoskeletal or nervous system effects.[43]
[46] [47] The EMA now recommends that
fluoroquinolone antibiotics be restricted for use
in serious, life-threatening bacterial infections
only.[43] The FDA has also issued certain
restrictions.[45] Despite this, a systemic
fluoroquinolone is usually required in patients
with non-necrotising otitis externa who have
comorbidities (diabetes or immunocompromised
state), as they are at higher risk for rapid
escalation from mild to severe manifestations
of AOE or for developing necrotising otitis
externa.[1] [12] [42] Advice should be sought
from an infectious diseases specialist to guide
selection of antibiotic and decide on whether
a fluoroquinolone is warranted here. In these
patients, cultures may be taken to assist in the
proper choice of oral antibiotics. Oral amoxicillin/
clavulanate or amoxicillin are other options to
cover  Staphylococcus aureus if Pseudomonas
aeruginosa is unlikely, or while awaiting results,
or if cultures are negative.
28 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
https://bestpractice.bmj.com
Otitis externa Management
Acute
» Prior to the use of topical ear drops, the ear
canal needs to be cleaned of any debris or wax
by dry swabbing or microsuction.[18] However,
irrigation should not be used to remove debris
from these patients’ ear canals, as this may
predispose the patients to necrotising otitis
externa.[1]
» Patients who have severe swelling of the ear
canal may have difficulty in using ear drops. A
wick should be inserted in the ear canal to allow
for drug delivery.
» Topical ciprofloxacin/dexamethasone,
ofloxacin, and ciprofloxacin can be used in
patients with perforated tympanic membranes
and so are preferred in this situation.[1] [31]
» Treatment course: a 10-day course is usually
sufficient.
adjunct pain management
Treatment recommended for SOME patients in
selected patient group
Primary options
» paracetamol: children: 10-15 mg/kg orally/
rectally every 4-6 hours when required,
maximum 75 mg/kg/day; adults: 500-1000
mg orally every 4-6 hours when required,
maximum 4000 mg/day
OR
» ibuprofen: children: 5-10 mg/kg orally every
6-8 hours when required, maximum 40 mg/
kg/day; adults: 200-400 mg orally every 4-6
hours when required, maximum 2400 mg/day
Secondary options
» paracetamol/codeine: children ≥12 years of
age: consult specialist for guidance on dose;
adults: 15-60 mg orally orally every 4-6 hours
Adults: dose refers to codeine component.
Maximum dose is based on paracetamol
component of 4000 mg/day.
OR
» oxycodone/paracetamol: adults: 5-10 mg
orally (immediate-release) every 4-6 hours
when required
Adults: dose refers to oxycodone component.
Maximum dose is based on paracetamol
component of 4000 mg/day.
M
A
NAG
EM
EN
T
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 21, 2023.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
29
https://bestpractice.bmj.com
Otitis externa Management
M
A
NA
G
EM
EN
T
Acute
» Analgesics increase patient satisfaction and
allow faster return to normal activities.
» Mild to moderate pain is usually controlled by
paracetamol or a non-steroidal anti-inflammatory
drug given alone or in combination with an opioid
(e.g., paracetamol with codeine or paracetamol
with oxycodone).[1] Analgesics should be started
at the initial recommended dose and adjusted
accordingly.
» Codeine is contraindicated in children younger
than 12 years, and it is not recommended
in adolescents aged 12-18 years who are
obese or have conditions such as obstructive
sleep apnoea or severe lung disease as it may
increase the risk of breathing problems.[61] It is
generally recommended only for the treatment
of acute moderate pain, which cannot be
successfully managed with other analgesics, in
children aged 12