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Otitis Externa (Acute)

NICE CKS Otitis externa. Last revised: May 2024. NICE BNF Treatment summaries Ear - Otitis externa

Background Information

Most common organisms:
  • Staphylococcus aureus
  • Pseudomonas aeruginosa

Environmental exposures:
  • Water in the ear (esp. polluted water)
  • Foreign body in the ear (e.g. ear plugs, hearing aids)
  • Trauma to the ear canal

Concurrent medical conditions:
  • Eczema
  • Psoriasis
  • Seborrhoeic dermatitis
  • Contact dermatitis
  • Acute otitis media (purulent middle ear secretions may enter the ear canal if the tympanic membrane is perforated)

Guidelines

Clinical diagnosis in most cases. Only consider ear swabs for micobiology if there is:
  • Treatment failure
  • Severe / recurrent / chronic otitis externa
  • Ear canal occlusion (due to swelling and debris) causing difficulty in applying topical treatments
  • Suspected spead of infection beyond the external auditory canal
 

Suspect acute otitis externa if:

  • At least one typical symptom (usually rapid-onset within 48 hours):
    • Itching of the ear canal
    • Ear pain and tenderness of the tragus and/or pinna +/- jaw pain
    • Ear discharge
    • Hearing loss (less common)
 
  • At least two typical signs:
    • Tenderness of the tragus and/or pinna
    • Red and oedematous ear canal
    • Tympanic membrane erythema 
    • Cellulitis of the pinna and adjacent skin
    • Conductive hearing loss (less common)
    • Tender regional lymphadenitis (less common)
 

Fungal infection is common in chronic otitis externa, suggestive signs are fluffy / cotton-like debris / hyphae / black debris in the ear canal

 

  • Consider OTCOver the counter acetic acid 2% ear drops / spray (if ≥12 y/o) for a maximum of 7 days
    • Reduces pH thus bacterial and fungal cell growth
 
  • Keep the ears clean and dry
    • Avoid swimming and water sports for at least 7-10 days
    • Use ear ear plugs and/or tight fitting cap when swimming
    • Keep shampoo, soap and water out of the ear when bathing and showering (e.g. use ear plugs or cotton wool)
 
  • Avoid damage to the external ear canal
    • Do not use cotton buds or other objects to clear the ear canal

Offer paracetamol or ibuprofen as needed for analgesia
 

Consider 7-14 days of
  • Topical antibiotic (gentamicin / ciprofloxacin) (NB gentamicin contraindicated if there is tympanic membrane perforation)
  • +/- topical steroid (prednisolone or betamethasone)

Consider oral antibitoics if:
  • Patient is immunocompromised
  • Severe infection
  • Spread beyond the external ear canal to adjacent tissues

Consider 
  • Topical fungal (clotrimazole)
  • +/- Topical steroid (prednisolone or betamethasone)

References

Author: Adams Lau
Reviewer:
Last edited: 12/07/25