Otitis Externa: Straight To The Point of Care

Otitis externa
Straight to the point of care
Last updated: Oct 23, 2019

Table of Contents
Overview 3
Summary 3
Definition 3
Theory 4
Epidemiology 4
Aetiology 4
Pathophysiology 4
Classification 4
Case history 5
Diagnosis 7
Approach 7
History and exam 8
Risk factors 9
Investigations 10
Differentials 12
Management 14
Approach 14
Treatment algorithm overview 17
Treatment algorithm 18
Primary prevention 33
Secondary prevention 33
Patient discussions 33
Follow up 34
Monitoring 34
Complications 34
Prognosis 34
Guidelines 35
Diagnostic guidelines 35
Treatment guidelines 35
References 36
Images 42
Disclaimer 43
Otitis externa Overview
Summary
Most commonly caused by Pseudomonas aeruginosa and Staphylococcus species.
Presents with rapid onset of ear pain, tenderness, itching, aural fullness, and hearing loss.
OVERVIEW
The development of malignant or necrotising otitis externa is more common in diabetic and
immunocompromised people.
Treatment of the uncomplicated form is cleaning of the ear canal and application of topical anti-infective
agents.
Definition
Acute otitis externa (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. The 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

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Otitis externa Theory
Epidemiology
AOE has a lifetime incidence of 10%.[1] 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
THEORY
age.[7] One review article estimated that AOE affects 4 in 1000 people annually in the US.[8] In a study done
in the UK, the 12-month prevalence of otitis externa was >1% and its prevalence was higher for females than
for males up to the age of 65 years.[9] In the same study, the incidence of otitis externa increased towards
the end of the summer, especially in the youngest age group (5-19 years old). It is common in warmer
temperatures and high-humidity conditions and after swimming.
Aetiology
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%-60%
prevalence) and Staphylococcus aureus (10%-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 (allergic dermatitis, atopic
dermatitis, psoriasis).[2] Fungal aetiology is uncommon in primary AOE, but may be more common in chronic
otitis externa or after treatment of AOE with antibiotics, particularly topical antibiotics. The most common
pathogens are Aspergillus species (60%-90%) and Candida species (10%-40%).[1]
Pathophysiology
The causes or pathogenesis are usually multifactorial. Several risk factors can predispose to infection or
initiate inflammation and subsequently the infectious process. Intact 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.[10] [11] 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 thought to be necessary for initiation of the inflammatory process.[12] [13]
Subsequently, oedema may result, followed by bacterial inoculation and overgrowth.
Classification
Scot t and 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.
Part of a generalised skin condition: patients have other skin conditions such as seborrheic dermatitis,
allergic dermatitis, atopic dermatitis, and psoriasis.
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Oct 23, 2019.
Invasive (granulomatous/necrotising/malignant) 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
THEORY
canal bone.
Bacterial versus fungal

Bacterial is more common than fungal. The most common pathogens are Pseudomonas aeruginosa and
Staphylococcus aureus . Fungal otitis externa is most commonly caused by Aspergillus species.
Malignant or necrotising
Occurs when the infection and inflammatory process involve not only the skin and soft tissue of the external
auditory canal but the bone tissue of the temporal bone as well.
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 due to the swelling. The concha and the pinna look normal. Neck
examination fails to reveal any lymphadenopathy.
Other presentations
Malignant or necrotising 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 malignant otitis externa, the infection
and the inflammatory process involve not only the skin and soft tissue of the external auditory canal but
the bone tissue of the temporal bone as well.[5] If left untreated, osteomyelitis of the petrous bone and/
or skull base could result.[5] [6] It is most commonly caused by Pseudomonas species.[1] [5] 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 in the floor of the canal.[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.
Otomycosis is fungal otitis externa. Acute fungal otitis externa is less common than acute bacterial otitis
externa.[1] It is most commonly caused by Aspergillus species.[3] It presents in a similar way with ear
pain, itching, aural fullness, and otorrhoea. Physical examination reveals swollen ear canal skin and
discharge. The presence of black spores indicates Aspergillus niger as the causative organism.[1] [3]
White filamentous hyphae can often be seen. The definitive diagnosis of otomycosis can be helped by
microscopic examination and ear cultures. Otomycosis should be suspected in patients who fail treatment
5
with antibacterial agents.[3] Secondary fungal infection of the external auditory canal is well known after
prolonged treatment with topical antibacterial agents.
THEORY
Otitis externa Diagnosis
Approach
Diagnosis is usually clinical, with patients presenting with rapid onset of symptoms.[3]
History and physical examination

Patients usually present within 48 hours of the following symptoms: ear pain, itching, and fullness, with or
without decreased hearing.[1] On physical examination there may be tenderness over the tragus, pinna,
or both, and manipulation of the ear canal is usually painful. The skin of the external auditory canal has
variable degrees of diffuse oedema, erythema, and swelling. 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. 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
Pneumatic otoscopy and/or tympanometry
DIAGNOSIS
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 AOE cases, tympanometry will be normal but will show 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 in 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 may reveal evidence of fungal infection. White
filamentous hyphae are seen in cases of fungal otitis externa (otomycosis). The presence of black spores
indicates Aspergillus niger as the causative organism.[1] [3]
7
Radiology
Computed tomography (CT) scans of the temporal bone with and without contrast are usually obtained
in patients who have severe otalgia despite the initiation of medical therapy, or in the presence of
granulation tissue in the ear canal, to rule out malignant otitis externa.[1] In similar situations, and in
cases where 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/malignant
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/malignant 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.
History and exam

Key diagnostic factors
presence of risk factors (common)
• Risk factors for AOE 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 AOE typically present with an acute onset of ear pain.[10]
DIAGNOSIS
tragal tenderness (common)

• The patient will usually complain of tenderness with manipulation of the tragus.[10]
ear canal swelling and erythema (common)

• On physical examination the skin of the external auditory canal appears erythematous and
swollen.[10]
granulation tissue in the ear canal (malignant otitis externa) (uncommon)

• A key factor in malignant otitis externa cases.[10]
Other diagnostic factors

otorrhoea (common)
• Discharge from the external auditory canal may be present in cases of acute otitis externa.[10]
aural fullness (common)

• Patients may complain of a fullness in the ears.[10]
itching (common)
• Patients may complain of itchiness in the ears.[10] 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.[10]
erythematous tympanic membrane (common)

• In addition to swelling in the external auditory canal, the tympanic membrane may appear
erythematous,[10] which can make exclusion and differentiation from acute otitis media difficult.
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.[8] This in itself, or in
the presence of additional risk factors, can cause infection. External auditory canal obstruction can be
caused by foreign bodies, a narrow ear canal, or bony exostosis.
high environmental humidity

• 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] Otitis
externa is the most common otologic disorder in divers, affecting almost half of all active divers at least
once.[14]
warmer environmental temperatures
DIAGNOSIS
• 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]
swimming
• 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]
local trauma
• Trauma disrupts the integrity of the external auditory canal skin and will initiate the process of
inflammation.[3] [15] 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 allergic dermatitis, atopic dermatitis, and psoriasis.[2]
9
diabetes
• Patients with diabetes, those who received irradiation, or those who are immunocompromised are
at higher risk for severe cases of otitis externa, and this fact can modify the management of those
patients.[1] [8]
immunocompromised
• Patients with diabetes, those who received irradiation, or those who are immunocompromised are
at higher risk for severe cases of otitis externa, and this fact can modify the management of those
patients.[1] [8]
prolonged used of topical antibacterial agents

• These agents may inhibit the normal flora after prolonged use on the external auditory canal, and their
use is a risk factor for fungal otitis externa.
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.
Investigations
1st test to order
Test Result
pneumatic otoscopy normal
• Normal in patients with AOE alone, but abnormal in patients with
otitis media alone or in combination with AOE.
tympanometry normal
DIAGNOSIS
• Normal in patients with AOE alone, but abnormal in patients with

otitis media alone or in combination with AOE. May cause discomfort
in patients with AOE.
Other tests to consider
Test Result
ear culture growth of the causative
pathogen
• Ear cultures are recommended in patients who fail to respond to
conventional therapy, and results will direct the choice of systemic
antibiotics.[3]
microscopy of exudate/debris from ear canal white filamentous hyphae
and/or black spores in
• White filamentous hyphae are seen on microscopic examination
otomycosis
of exudate/debris from the ear canal in cases of fungal otitis
externa (otomycosis).The presence of black spores indicates
Aspergillus niger as the causative organism in fungal otitis externa
(otomycosis).[1] [3]
CT scan of the temporal bone with intravenous contrast bony erosion and invasion
of petrous apex or skull
• CT scans are recommended in patients who have persistent severe
base
ear pain and fullness despite adequate medical therapy with topical
and oral antibiotics. This is to rule out malignant 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
diabetic or immunocompromised patients.[1]
MRI of the brain and internal auditory canals (with and without soft tissue outside the
gadolinium) confines of the external
auditory canal
• Ordered in addition to CT scan when malignant or necrotising otitis
externa is suspected, especially in diabetic or immunocompromised
patients.
DIAGNOSIS
11
Differentials
Condition Differentiating signs / Differentiating tests

symptoms
Acute otitis media • Acute otitis media and • Tympanometry will reveal a
AOE present with ear pain. normal peaked curve in AOE
Hearing loss may be present but a flat (type B) curve in
in both. Tympanic membrane acute otitis media.[10]
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.[10]
Furunculosis • Furunculosis is sometimes • No differentiating tests.

referred to as localised
AOE.[10] It usually
represents a localised
infected hair follicle in the
cartilaginous portion of
the ear canal.[17] 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
DIAGNOSIS
of the ear canal.[12] The

bony (medial) portion of the
external auditory canal is
usually normal.
Contact dermatitis of the • This is an allergic reaction • No differentiating tests.

ear canal to antigens that could be
present in hearing aid
material, cosmetics, and
other topical otic solutions.
Patients usually give history
of prior use of topical
solutions.
• Among the topical solutions,
neomycin is the most
commonly implicated
agent.[10] Patients with
allergies to otic topical
solutions usually present
with erythema and oedema
that extend into the conchal
bowl.
Condition Differentiating signs / Differentiating tests

symptoms
Viral infections of the • Severe otalgia, facial • No differentiating tests.
external ear paralysis or paresis, taste
disturbance on the anterior
two-thirds of the tongue, and
decreased lacrimation on the
affected side.[10] Physical
examination may reveal
erythema and/or vesicles in
the ear canal and auricle.[12]
Chronic otitis externa • Chronic otitis externa is • No differentiating tests.

inflammation of the ear canal
skin. 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.[12] 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]
Cancer of the external • Recalcitrant to usual medical • Biopsy of the external

auditory canal therapy. auditory canal.[10]
DIAGNOSIS
Cholesteatoma • Consider particularly in • CT can help with confirming
recalcitrant cases not the diagnosis, assessing
responding to medical disease extension, and
therapy. Otoscopy typically treatment planning.
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.
Ear canal cholesteatoma • Rare disease of the external • CT may reveal a localised
auditory canal. It usually cholesteatoma, with or
presents with ear discharge, without extension into the
focal erosion, and keratin middle ear or mastoid cavity.
accumulation in the bony ear
canal.[18]
13
Otitis externa Management
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.[19] This allows the status of the tympanic membrane to
be checked as well as enhancing skin penetration of the topical solution.[8] When applying ear drops, the
patient should be advised to apply the drops lying down with the affected ear upwards and wait for 5 to 10
minutes before getting up.
Bacterial
Several ear drops are available for first-line treatment. Studies have failed to demonstrate difference in
outcome with different products.[1] [20] The choice of the ear drop should be based on patient preference,
with 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.[21]
Currently, topical antibiotic solutions are more commonly used in AOE.[22] Neomycin- and polymyxin
B-containing solutions were one of the first antibiotic ear drops to be used and demonstrated efficacy
against pathogens causing AOE. The addition of a corticosteroid to such preparations was found to
hasten symptomatic relief.[25] However, solutions containing neomycin or polymyxin-B are to be avoided
in patients with tympanic membrane perforation due to potential ototoxicity.[1] [22]
Fluoroquinolone-containing (ciprofloxacin and ofloxacin) agents have become available and are
effective against both the gram-negative and gram-positive pathogens that are common in otitis
externa.[22] In one systematic review of the literature, it was found that a combined ciprofloxacin/
dexamethasone preparation is safe and effective in patients with acute otitis externa.[28] One meta-
analysis found that fluoroquinolone-containing ear drops are superior to combination drugs not containing
a fluoroquinolone.[29] Hypersensitivity to fluoroquinolone ear drops is not very common, and they can be
used in patients with tympanic membrane perforations.[1] [22] However, one retrospective cohort study
found that the use of fluoroquinolone-containing ear drops to treat acute otitis externa is associated with a
previously unreported increased risk of developing tympanic membrane perforation,[30] although this has
not yet changed clinical practice.
The usual dose of the fluoroquinolone-containing ear drops is twice daily, compared with the older
solutions where the dosage is three times daily, which might have a favourable effect on compliance. In a
randomised clinical study of patients with acute otitis externa, it was found that a combined ciprofloxacin/
dexamethasone preparation resulted in less time to cure when compared with polymyxin B/neomycin/
hydrocortisone otic suspension.[31] Another randomised clinical trial found ciprofloxacin/dexamethasone
otic to be equal in effectiveness to topical neomycin/polymyxin B/hydrocortisone administered with
systemic amoxicillin in the treatment of acute otitis externa.[32] These observations have produced a shift
in treatment preference towards the fluoroquinolone-containing ear drops.[22] However, the older topical
solutions are still very commonly used and their cost is lower, making them more affordable.
MANAGEMENT
A new fluoroquinolone, finafloxacin, is approved by the US Food and Drug Administration (FDA) for topical
use for treatment of acute otitis externa caused by susceptible strains of Pseudomonas aeruginosa and
Staphylococcus aureus .
Care should be exercised in patients who are known, or suspected, to have a tympanic membrane
perforation to avoid ototoxic ear drops (those that contain aminoglycosides and alcohol).[1] In that
situation, ofloxacin or ciprofloxacin/dexamethasone can be used.[1]
For patients who fail to show response to initial ear drop treatment within 48 to 72 hours, culture of the
external auditory canal and additional cleaning of the ear canal from debris are recommended. Unless
there is evidence of fungal infection, such patients benefit from the addition of oral antibiotics. Culture and
sensitivity may help to guide antibiotic therapy in refractory cases.
Patients with other medical problems

Patients with diabetes, those who have received irradiation, or those who are immunocompromised
are at higher risk for rapid escalation from mild to severe manifestations or for developing malignant
otitis externa.[8] [33] 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] [15]
Oral ciprofloxacin is an effective medication; however, it is not generally recommended in children.[15]

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.[34] The UK-based Medicines and Healthcare products Regulatory
Agency support these recommendations.[35] The FDA issued a similar safety communication in 2016,
restricting the use of fluoroquinolones in acute sinusitis, acute bronchitis, and uncomplicated urinary
tract infections.[36] 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.[37] [38]
Despite this, a systemic fluoroquinolone is usually required in patients with non-malignant/non-necrotizing

otitis externa who have comorbidities, as they are at higher risk for rapid escalation from mild to severe
manifestations, or for developing malignant otitis externa. 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.
For patients who fail to show response to initial ear drop treatment, culture of the external auditory canal
and additional cleaning of the ear canal from debris are recommended. Culture and sensitivity may help
to guide alternative antibiotic therapy in refractory cases.
MANAGEMENT
Malignant or necrotising otitis externa

All patients in this group should have debridement of granulation tissue. Patients can be given oral
ciprofloxacin for 6 to 8 weeks.[39] Oral ciprofloxacin has good coverage against Pseudomonas
15
and is very commonly and successfully used in these patients. Oral fluoroquinolones are active
against Pseudomonas aeruginosa , penetrate bone well, have excellent oral bioavailability, and
have a less significant side effect profile compared with alternatives.[40] If patients have failed to
respond to ciprofloxacin, they should be started on intravenous antibiotics that have anti-pseudomonas
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).[41] [42] 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 refractory or recurrent cases or in patients with extensive skull
base or intracranial involvement.[41] One systematic review about the use of hyperbaric oxygen as an
adjuvant treatment for malignant otitis externa failed to show clear evidence demonstrating its efficacy
when compared with treatment with antibiotics and/or surgery.[43]
Fungal
The first line of treatment of fungal otitis externa is still in debate.[3] However, the use of acidifying
agents is effective in most cases.[44] Patients who fail treatment with acidifying agents can be started
on antifungal topical treatment.[44] If Candida is cultured, an oral antifungal (e.g., fluconazole,
itraconazole) may help.[15] [45] Further studies are needed to assess the benefit of oral antifungal agents
in otomycosis.[45] Repeated ear cleaning is also an essential part of treatment. In patients with tympanic
membrane perforation, tolnaftate should be used to prevent ototoxicity.[44] AOE secondary to Aspergillus
infections may require the use of oral itraconazole.[44] If fungal otitis externa is refractory to treatment and
there is progression of disease, consider fungal malignant otitis externa.[46]
Severe swelling of the ear canal

Patients who have severe swelling of the ear canal may have difficulty in applying the ear drops.
A wick should be inserted in the ear canal to allow for drug delivery. Such wicks are often made of
dry, compressed Merocel® 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. A study of three different packing
materials in the treatment of severe acute otitis externa 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.[47]
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 (e.g., paracetamol with codeine or oxycodone; or ibuprofen with
oxycodone).[1] Codeine is contraindicated in children younger than 12 years of age, and it is not
MANAGEMENT
recommended in adolescents 12 to 18 years of age who are obese or have conditions such as obstructive
sleep apnoea or severe lung disease as it may increase the risk of breathing problems.[48] It is generally
recommended only for the treatment of acute moderate pain, which cannot be successfully managed with
other analgesics, in children 12 years of age and older. It should be used at the lowest effective dose for
the shortest period and treatment limited to 3 days.[49] [50]
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 1st antibacterial otic drops

otherwise healthy people
adjunct pain management
refractory to initial 1st topical and systemic antibacterial therapy

treatment, or diabetic or
immunocompromised
malignant or necrotising 1st topical and systemic antibacterial therapy

plus debridement
adjunct hyperbaric ox ygen
2nd intravenous antibiotic therapy plus

debridement
fungal
initial treatment, non- 1st topical or oral treatment

perforated tympanic
membrane
perforated tympanic 1st tolnaftate otic drops

membrane

MANAGEMENT
17
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
MANAGEMENT
Acute
bacterial
initial treatment in 1st antibacterial otic drops

otherwise healthy people
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
» finafloxacin otic: (0.3%) children and adults:

4 drops into the affected ear(s) twice daily for
7 days
For patients requiring use of an otowick,
the initial dose can be doubled to 8 drops,
followed by 4 drops twice daily.
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
OR
» acetic acid otic: (2%) children and adults:

3-5 drops into the affected ear(s) three times
daily for 7-10 days
OR
MANAGEMENT
» 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
19
Acute
» Initial treatment refers to otherwise healthy
people without any extension to the outside ear
canal.
» Prior to the use of topical ear drops, the ear

canal needs to be cleaned of any debris or wax.
» Patients who have severe swelling of the ear

canal may have difficulty in applying ear drops. A
wick should be inserted in the ear canal to allow
for drug delivery.
» Ciprofloxacin/dexamethasone and ofloxacin

can be used in patients with perforated tympanic
membranes.
» Ototoxic ear drops (those that contain

aminoglycosides and alcohol) should be
avoided in patients with possible tympanic
perforations.[1]
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

MANAGEMENT
orally (immediate-release) every 4-6 hours

when required
Adults: dose refers to oxycodone component.
Acute
OR
» oxycodone/ibuprofen: adults: 5 mg/400 mg

(1 tablet) orally every 6 hours when required,
maximum 4 tablets/day
» Initial treatment refers to otherwise healthy

people without any extension to the outside ear
canal.
» 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, or ibuprofen with oxycodone).[1]
Analgesics should be started at the initial
recommended dose and adjusted accordingly.
» Codeine is contraindicated in children younger

than 12 years of age, and it is not recommended
in adolescents 12 to 18 years of age who are
obese or have conditions such as obstructive
sleep apnoea or severe lung disease as it may
increase the risk of breathing problems.[48] It is
generally recommended only for the treatment
of acute moderate pain, which cannot be
successfully managed with other analgesics, in
children 12 years of age and older. It should be
used at the lowest effective dose for the shortest
period and treatment limited to 3 days.[49] [50]
refractory to initial 1st topical and systemic antibacterial therapy
treatment, or diabetic or
Primary options
immunocompromised
» 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
MANAGEMENT
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
21
Acute
(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--
daily
-or-
daily; adults: 10 drops into the affected ear(s)
once daily
» Patients who fail to respond to initial treatment

or who are diabetic or immunocompromised
benefit from the addition of oral 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.[34]
[37] [38] The EMA now recommends that
fluoroquinolone antibiotics be restricted for use
in serious, life-threatening bacterial infections
only.[34] The FDA has also issued certain
restrictions.[36] Despite this, a systemic
fluoroquinolone is usually required in patients
with non-malignant/non-necrotizing otitis externa
who have comorbidities, as they are at higher
risk for rapid escalation from mild to severe
manifestations or for developing malignant
otitis externa. 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,
MANAGEMENT
or if cultures are negative.
» Prior to the use of topical ear drops, the ear

canal needs to be cleaned of any debris or wax.
Acute
for drug delivery.
» Topical ciprofloxacin/dexamethasone and

ofloxacin can be used in patients with perforated
tympanic membranes and so are preferred in
this situation.
» Treatment course: a 10-day course is usually

sufficient.
Primary options

maximum 4000 mg/day
OR

Secondary options

OR

when required
OR
MANAGEMENT

23
Acute


malignant or 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--
daily for 7-10 days
-or-
daily for 7 days; adults: 10 drops into the
affected ear(s) once daily for 7 days
» All patients in this group should have

debridement of granulation tissue.
» 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
MANAGEMENT
adverse effects include tendonitis, tendon

rupture, arthralgia, neuropathies, and other
musculoskeletal or nervous system effects.[34]
[37] [38] The EMA now recommends that
fluoroquinolone antibiotics be restricted for use
in serious, life-threatening bacterial infections
Acute
only.[34] The FDA has also issued certain
restrictions.[36] Despite this, a systemic
fluoroquinolone is required in patients with
malignant/necrotizing otitis externa.
» Oral fluoroquinolones are active against

Pseudomonas aeruginosa , penetrate bone well,
have excellent oral bioavailability, and have a
less significant side effect profile compared with
alternatives.[40]
» Topical ciprofloxacin/dexamethasone or
ofloxacin can be used in conjunction with
systemic ciprofloxacin and are safe to use in
patients with tympanic perforation.[1] Ototoxic
ear drops (those that contain aminoglycosides
and alcohol) should be avoided in patients with
possible tympanic perforations.[1]
» Hyperbaric oxygenation can be used in
refractory or recurrent cases, or in patients
with extensive skull base or intracranial
involvement[41] although, in one systematic
review, no clear evidence was found in
demonstrating its efficacy when compared to
treatment with antibiotics and/or surgery.[43]
Primary options

maximum 4000 mg/day
OR

Secondary options
MANAGEMENT

25
Acute
OR

when required
OR




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
MANAGEMENT
OR
» ticarcillin/clavulanic acid: children: consult

specialist for guidance on dose; adults: 3.2
Acute
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
» 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.
» If patients have failed to respond to

ciprofloxacin, they should be started on
intravenous antibiotics that have anti-
pseudomonas 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,
MANAGEMENT
tobramycin).[41] [42] 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.
27
Acute
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.
» Hyperbaric oxygenation can be used in
refractory or recurrent cases, or in patients
with extensive skull base or intracranial
involvement[41] although, in one systematic
review, no clear evidence was found in
demonstrating its efficacy when compared to
treatment with antibiotics and/or surgery.[43]
Primary options

maximum 4000 mg/day
OR

Secondary options

OR

when required
MANAGEMENT
OR
Acute



fungal
initial treatment, non- 1st topical or oral treatment

perforated tympanic
Primary options
membrane
» 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
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
MANAGEMENT
» fluconazole: children and adults: consult

specialist for guidance on dose
OR
29
Acute
» itraconazole: children and adults: consult
specialist for guidance on dose
» Frequent cleaning 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.

for drug delivery.
» Oral antifungals may be used if caused by

candidal infection. Further studies are needed
to assess the benefit of oral antifungal agents in
otomycosis.[45] Dose and duration of treatment
for such an indication have not been fully
studied. Itraconazole may be used if caused by
Aspergillus infection.[44].
Primary options

maximum 4000 mg/day
OR

Secondary options

OR

MANAGEMENT

when required
Acute
OR




perforated tympanic 1st tolnaftate otic drops
membrane
Primary options
» tolnaftate topical: (1%) children ≥2 years of

age and adults: 3-4 drops into the affected
ear(s) three to four times daily for 7 days
» Frequent cleaning 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.
Primary options

MANAGEMENT
maximum 4000 mg/day
OR
31
Acute
Secondary options

OR

when required
OR




MANAGEMENT
Primary prevention
Primary prevention of AOE 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.[10] This can be achieved by avoidance of water accumulation and retention in the ear canal.[10]
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 efficacy of different strategies in prevention, but recommendations have been made in the
literature.[10] These include removal of obstructing cerumen,[16] water precautions, the use of acidifying
ear drops after swimming, and avoidance of trauma to the ear canal from cotton-tipped applicators and
other objects. 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.[10] [11]
Secondary prevention
Patients should be advised to avoid the use of foreign bodies in the ear. Patients with underlying skin
disorders should be treated. 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.[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 diabetic patients.
MANAGEMENT
33
Otitis externa Follow up
Monitoring
Monitoring
FOLLOW UP
Patients do not usually require long-term monitoring. Patients who develop recurrent episodes should be
assessed for the presence of risk factors.
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 (such as ciprofloxacin/dexamethasone otic)
usually help.
cranial nerve palsy variable medium
Occurs mainly in association with malignant/necrotising otitis externa. One case series found 40% (15/37)
of cases had facial nerve palsy and 24% (9/37) had multiple cranial nerve palsies.[51]
osteomyelitis of the skull base variable low
A complication of malignant/necrotising otitis externa, which 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 to 10 days, regardless of agent used.[1]
The mortality rate of malignant otitis externa has decreased over the years from 50% to 0%-15%.[40] Facial
nerve paralysis is a poor prognostic factor, and its presence indicates the need for longer treatment.[40]
In such cases, 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 MRI are other poor prognostic indicators
in patients with malignant otitis externa.[40]
Predisposing factors
A search for predisposing factors is helpful and sometimes necessary in patients with recurrent AOE.
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.
Otitis externa Guidelines
Diagnostic guidelines
North America
Practice point: acute otitis externa (ht tps://www.cps.ca/en/documents)

Published by: Canadian Paediatric Society Last published: 2013;
Reaffirmed: 2018
Treatment guidelines
North America
Clinical practice guideline: acute otitis externa (ht tp://www.entnet.org/

content/clinical-practice-guidelines)
GUIDELINES
Published by: American Academy of Otolaryngology-Head and Neck Last published: 2014
Surgery Foundation
Practice point: acute otitis externa (ht tps://www.cps.ca/en/documents)

Published by: Canadian Paediatric Society Last published: 2013;
Reaffirmed: 2018
35
Otitis externa References
Key articles
• Rosenfeld RM, Schwartz SR, Cannon CR, et al. American Academy of Otolaryngology-Head and
REFERENCES
Neck Surgery Foundation. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck
Surg. 2014 Feb;150(1 Suppl):S1-S24. Full text (http://oto.sagepub.com/content/150/1_suppl/S1.long)
Abstract (http://www.ncbi.nlm.nih.gov/pubmed/24491310?tool=bestpractice.bmj.com)
• Rosenfeld RM, Schwartz SR, Cannon CR, et al. American Academy of Otolaryngology-Head and
Surg. 2014;150(suppl 1):S1-S24. Full text (http://oto.sagepub.com/content/150/1_suppl/S1.long)
• Osguthorpe JD, Nielsen DR. Otitis externa: review and clinical update. Am Fam Physician.
2006;74:1510-1516. Full text (http://www.aafp.org/afp/20061101/1510.html) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/17111889?tool=bestpractice.bmj.com)
• Hirsch BE. Infections of the external ear. Am J Otolaryngol. 1992;13:145-155. Abstract (http://
• Selesnick SH. Otitis externa: management of the recalcitrant case. Am J Otology. 1994;15:408-412.
• Mösges R, Nematian-Samani M, Hellmich M, et al. A meta-analysis of the efficacy of quinolone

containing otics in comparison to antibiotic-steroid combination drugs in the local treatment of otitis
externa. Curr Med Res Opin. 2011 Oct;27(10):2053-60. Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/21919557?tool=bestpractice.bmj.com)
References
1. Rosenfeld RM, Schwartz SR, Cannon CR, et al. American Academy of Otolaryngology-Head and
Surg. 2014 Feb;150(1 Suppl):S1-S24. Full text (http://oto.sagepub.com/content/150/1_suppl/S1.long)
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
(http://www.ncbi.nlm.nih.gov/pubmed/1626615?tool=bestpractice.bmj.com)
4. Lee SK, Lee SA, Seon SW, et al. Analysis of prognostic factors in malignant external otitis. Clin
Exp Otorhinolaryngol. 2017 Sep;10(3):228-35. Full text (https://www.e-ceo.org/journal/view.php?
id=10.21053/ceo.2016.00612) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/27671716?
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5. Walshe P, Cleary M, McConn WR, et al. Malignant otitis externa: a high index of suspicion is still
needed for diagnosis. Irish Med J. 2002 Jan;95(1):14-6. Abstract (http://www.ncbi.nlm.nih.gov/
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2014 May;124(5):1083-7. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/24115113?
7. Roland PS, Stroman DW. Microbiology of acute otitis externa. Laryngoscope. 2002 Jul;112(7 Pt
1):1166-77. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/12169893?tool=bestpractice.bmj.com)
8. Osguthorpe JD, Nielsen DR. Otitis externa: review and clinical update. Am Fam Physician. 2006
Nov 1;74(9):1510-6. Full text (http://www.aafp.org/afp/20061101/1510.html) Abstract (http://
9. Rowlands S, Devalia H, Smith C, et al. Otitis externa in UK general practice: a survey using the
UK General Practice Research Database. Br J Gen Pract. 2001 Jul;51(468):533-8. Full text
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314044/pdf/11462312.pdf) Abstract (http://
10. Rosenfeld RM, Schwartz SR, Cannon CR, et al. American Academy of Otolaryngology-Head and
Surg. 2014;150(suppl 1):S1-S24. Full text (http://oto.sagepub.com/content/150/1_suppl/S1.long)
11. Osguthorpe JD, Nielsen DR. Otitis externa: review and clinical update. Am Fam Physician.
2006;74:1510-1516. Full text (http://www.aafp.org/afp/20061101/1510.html) Abstract (http://
12. Hirsch BE. Infections of the external ear. Am J Otolaryngol. 1992;13:145-155. Abstract (http://
13. Selesnick SH. Otitis externa: management of the recalcitrant case. Am J Otology. 1994;15:408-412.
14. Livingstone DM, Smith KA, Lange B. Scuba diving and otology: a systematic review
with recommendations on diagnosis, treatment and post-operative care. Diving Hyperb
Med. 2017 Jun;47(2):97-109. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/28641322?
15. 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)
16. Schwartz SR, Magit AE, Rosenfeld RM, et al. Clinical practice guideline (update): earwax
(cerumen impaction). Otolaryngol Head Neck Surg. 2017 Jan;156(1_suppl):S1-29. Full text (http://
journals.sagepub.com/doi/pdf/10.1177/0194599816671491) Abstract (http://www.ncbi.nlm.nih.gov/
37
17. Chan KL, Soo G, van Hasselt CA. Furunculosis. Ear Nose Throat J. 1997;76:126. Abstract (http://
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18. Dubach P, Mantokoudis G, Caversaccio M. Ear canal cholesteatoma: meta-analysis of clinical

characteristics with update on classification, staging and treatment. Curr Opin Otolaryngol Head
Neck Surg. 2010 Oct;18(5):369-76. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/20717034?
19. Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician. 2012 Dec
1;86(11):1055-61. Full text (https://www.aafp.org/afp/2012/1201/p1055.html) Abstract (http://
20. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database Syst
Rev. 2010 Jan 20;(1):CD004740. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/20091565?
21. Kantas I, Balatsouras DG, Vafiadis M, et al. The use of trichloroacetic acid in the treatment of acute
external otitis. Eur Arch Otorhinolaryngol. 2007 Jan;264(1):9-14. Abstract (http://www.ncbi.nlm.nih.gov/
22. Dohar JE. Evolution of management approaches for otitis externa. Pediatr Infect Dis J. 2003
Apr;22(4):299-305; quiz 306-8. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/12690268?
23. van Balen FA, Smit WM, Zuithoff NP, et al. Clinical efficacy of three common treatments in acute
otitis externa in primary care: randomised controlled trial. BMJ. 2003;327:1201-1205. Full text
(http://www.bmj.com/cgi/content/full/327/7425/1201) Abstract (http://www.ncbi.nlm.nih.gov/
24. Lambert IJ. A comparison of the treatment of otitis externa with "Otosporin" and aluminium acetate:
a report from a services practice in Cyprus. J R Coll Gen Pract. 1981;31:291-294. Full text (http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC1971024/pdf/jroyalcgprac00101-0037.pdf) Abstract (http://
25. Mösges R, Schröder T, Baues CM, et al. Dexamethasone phosphate in antibiotic ear drops for the
treatment of acute bacterial otitis externa. Curr Med Res Opin. 2008 Aug;24(8):2339-47. Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/18606053?tool=bestpractice.bmj.com)
26. Pistorius B, Westberry K, Drehobl M, et al. Prospective, randomized, comparative trial of ciprofloxacin
otic drops, with or without hydrocortisone, vs. polymyxin B-neomycin-hydrocortisone otic suspension in
the treatment of acute diffuse otitis externa. Infect Dis Clin Pract. 1999;8:387-395.
27. Jones RN, Milazzo J, Seidlin M. Ofloxacin otic solution for treatment of otitis externa in children and
adults. Arch Otolaryngol Head Neck Surg. 1997;123:1193-1200. Abstract (http://www.ncbi.nlm.nih.gov/
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41
Otitis externa Images
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
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Contributors:
// Authors:
Soha Ghossaini, MD, FACS

Otology-Neurotology
Ear, Nose and Throat Associates of New York, Flushing, New York, NY
DISCLOSURES: SG declares that she has no competing interests.
// Peer Reviewers:
Peter S. Roland, MD
Professor Neurological Surgery
Chief of Pediatric Otology, Otolaryngology Head and Neck Surgery, UT Southwestern Medical Center,
Dallas, TX
DISCLOSURES: PSR has acted as a consultant to Alcon laboratories, makers of Ciprodex®, who
have provided compensation to the University of Texas Southwestern Medical Center Department of
Otolaryngology Head and Neck Surgery. PSR has received compensation for speaking and for organizing
educational events. PSR is co-author of the American Academy of Head and Neck Surgery's practice
guideline for AOE. PSR is an author of references cited in 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.

Otitis Externa: Straight To The Point of Care

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Otitis Externa: Straight To The Point of Care

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Otitis externa

Straight to the point of care

Last updated: Oct 23, 2019

Diagram of acute otitis externa

Bacterial versus fungal

History and physical examination

Pneumatic otoscopy and/or tympanometry

Culture and microscopy

Re-evaluation in patients refractory to treatment

History and exam

ear pain (common)

tragal tenderness (common)

ear canal swelling and erythema (common)

granulation tissue in the ear canal (malignant otitis externa) (uncommon)

Other diagnostic factors

aural fullness (common)

decreased hearing (common)

erythematous tympanic membrane (common)

high environmental humidity

warmer environmental temperatures

prolonged used of topical antibacterial agents

• Normal in patients with AOE alone, but abnormal in patients with

Other tests to consider

Condition Differentiating signs / Differentiating tests

Furunculosis • Furunculosis is sometimes • No differentiating tests.

of the ear canal.[12] The

Contact dermatitis of the • This is an allergic reaction • No differentiating tests.

Condition Differentiating signs / Differentiating tests

Chronic otitis externa • Chronic otitis externa is • No differentiating tests.

Cancer of the external • Recalcitrant to usual medical • Biopsy of the external

Patients with other medical problems

Oral ciprofloxacin is an effective medication; however, it is not generally recommended in children.[15]

Despite this, a systemic fluoroquinolone is usually required in patients with non-malignant/non-necrotizing

Malignant or necrotising otitis externa

Severe swelling of the ear canal

Treatment algorithm overview

initial treatment in 1st antibacterial otic drops

adjunct pain management

refractory to initial 1st topical and systemic antibacterial therapy

adjunct pain management

malignant or necrotising 1st topical and systemic antibacterial therapy

adjunct hyperbaric ox ygen

adjunct pain management

2nd intravenous antibiotic therapy plus

adjunct hyperbaric ox ygen

adjunct pain management

initial treatment, non- 1st topical or oral treatment

adjunct pain management

perforated tympanic 1st tolnaftate otic drops

adjunct pain management

initial treatment in 1st antibacterial otic drops

» ofloxacin otic: (0.3%) children ≥6 months

» finafloxacin otic: (0.3%) children and adults:

» ciprofloxacin/hydrocortisone otic: (0.2%/1%)

» neomycin/polymyxin B/hydrocortisone otic:

» acetic acid otic: (2%) children and adults:

» acetic acid/hydrocortisone otic: (2%/1%)

» Prior to the use of topical ear drops, the ear

» Patients who have severe swelling of the ear

» Ciprofloxacin/dexamethasone and ofloxacin

» Ototoxic ear drops (those that contain

» paracetamol: children: 10-15 mg/kg orally/

» ibuprofen: children: 5-10 mg/kg orally every