Otitis Externa

 

This guideline applies to children and adults.

 

Introduction

Otitis externa (OE) is inflammation of the external auditory canal. It can be:

• Acute (symptoms less than 6 weeks) – usually due to an infection, either bacterial or fungal, or both.

• Chronic (more than 3 months) – typically due to an underlying inflammatory skin condition, exacerbated by excessive scratching or cleaning.

• Malignant – less common, but potentially life-threatening infection, resulting in osteomyelitis of the base of the skull. More common in the elderly, diabetic patients and those with immunosuppression.

 

Red Flag Features

OE with:

• Systemic upset
• Pinna / facial cellulitis
• Features of malignant OE
• Poorly controlled / uncontrolled pain
• Ear canal swelling preventing effective topical treatment

 

In context of discharging ear(s):

• Features of mastoiditis
• Postauricular swelling

 

Persistent ear canal infection / bleeding / pain should raise the rare possibility of cancer of the ear canal. This can be difficult to distinguish clinically from malignant OE in primary care.

 

Key Features of Assessment

 

Acute and chronic OE typically present with itch, dry flaky skin around the external meatus of the ear canal and otorrhoea (serous or purulent). Otalgia can be feature of acute OE, but is rare in chronic cases. It is less common to get reduced hearing, but this can be seen in severe cases.

 

Malignant OE:

• Unremitting, disproportionate otalgia
• Otorrhoea - typically purulent
• Vertigo
• Profound/severe hearing loss
• Ipsilateral facial palsy
• Systemic upset, including fever, malaise, headaches

 

Risk factors:

• Water exposure
• Trauma e.g. recent microsuction / cotton buds
• Hearing aids
• Abnormal ear canal or previous surgery
• Inflammatory dermatoses e.g. eczema, psoriasis
• Malignant OE – elderly, diabetic, immunocompromised

 

On examination:

• Features suggestive of OE:
  • Tenderness of tragus or pinna
  • Ear canal swelling / erythema with dry scaly / moist skin and scanty otorrhoea (serous or purulent)
• Check whether TM intact, as this might influence treatment options
• Rule out red flag features

 

 

Investigations

 

Consider:

• Screening for diabetes:
  • at-risk groups
  • recurrent or severe infection
• Ear swab:
  • severe, recurrent or persistent (more than 2 weeks) infection
  • pinna and/or facial cellulitis
  • swelling of ear canal making application of ear drops challenging

 

Primary Care Management

 

In the absence of red flag features:

1.     Provide patient information

2.     Advise to keep ears dry for at least 7 to 10 days during treatment:

o   Use precautions to prevent water ingress when bathing, showering, etc. Advise using silicone swim plugs (available from pharmacies), a ball of cotton wool soaked in petroleum jelly or adhesive putty positioned in the outer bowl of the ear (and not pushed into the canal).

o   Avoid getting soap, shampoos, and conditioners in ears as detergents can irritate the ear skin.

o   Avoid water sports i.e. swimming or surfing, and putting head under water.

3.     Avoid cotton buds or any other implement to try and clean the ears.

4.     Offer local treatment (see below).

5.     If OE with pinna / facial cellulitis, in a well patient, consider discussing with ENT first on-call for specialist advice before commencing oral antibiotics

 

Local treatment options

National guidelines support giving children and adults and children antibiotic ear drops (including aminoglycosides) for discharging ears. Risk to hearing is greater by not treating, than from aminoglycoside drops. Locorten vioform is not recommended, as its consistency is such that administration is suboptimal.

 

Intact TM:

*EarCalm is not a treatment for infection (as it contains no antibiotic) and is only helpful for the itchiness associated with OE.

 

Suspected or known TM perforation, or t-tube/grommets in situ:

Non-ototoxic drops are preferred e.g. topical ciprofloxacin or ofloxacin:

• RCHT Primary Care Antibiotic Guideadvises that use of ciprofloxacin (Cetraxal 2mg/ml) ear drops 0.25ml unit dose is licensed for OE and may be used with specialist ENT input.
• RCHT ENT specialist advises Cilodex (ciprofloxacin and dexamethasone) as an alternative.
• Regarding use in children, there is insufficient clinical experience on the use of Cilodex in children under 6 months in treatment of middle ear infections, and in children under 1 year in treatment of outer ear infections¹.

 

 

Advice and guidance

Seek ENT Advice and Guidance for:

• Diagnostic uncertainty
• Suspected ear canal cancer (do not send via ENT 2WW or urgent OPA referral).

Pinna lesions suspicious of skin cancer should be referred via dermatology suspected cancer (2WW) pathway.

To discuss a patient with the Aural Care Service at RCHT, please email rcht.auralcareservice@nhs.net.

 

 

Referral

Same Day

In adults with red flag features, discuss with ENT first on-call to arrange admission:

• Unwell patient with OE and/or pinna or facial cellulitis
• Malignant OE
• Poorly controlled / uncontrolled pain
• Ear canal swelling preventing effective topical treatment
• Mastoiditis
• Postauricular swelling

 

In unwell children, arrange admission via paediatric on-call who will typically liaise with ENT as required.

If there is profuse otorrhoea preventing the application of ears drops, in a relatively well child, consider contacting ENT first on-call in the first instance to arrange review for microsuction.

 

 

 

Planned care

ENT Emergency Treatment Clinic

Accessed via discussion with ENT first on-call:

• Persistent symptoms (more than 2 weeks) despite treatment (also arrange ear swab if able)

 

Urgent or routine adult ENT referral

• Recurrent OE – 3 episodes in 6 months, or 4 episodes in 12 months
• Large or recurrent TM perforation

 

Urgent or routine paediatric ENT referral

• Child, aged under 18 years, with a painless discharging ear that is not responding to topical treatment and there are no red flag features

 

Aural Care Service

For consideration of microsuction:

• Adult, aged 18 years or over, with a painless discharging ear that is not responding to topical treatment and there are no red flag features

Exclusion criteria (Aural Care Service):

• Referral for hearing test
• Removal of wax:
• not meeting inclusion criteria
• for audiology purposes
• due to unsuccessful private removal attempt, or lack of affordability

 

Minimum required information for referral

• Patient symptoms and examination findings
• Confirmation that:
  • the full course of recommended drops has been completed
  • contraindications to irrigation (if referring to Aural Care)
• Results of any relevant investigations
• Whether patient is known to ENT services

 

 

Supporting Information

 

For professionals:

NICE CKS – Otitis Externa

Patient UK – Otitis Externa (for medical professionals)

RCHT Primary Care Antibiotic Guide, pg. 5-6

 

For patients:

Patient UK – Otitis Externa

Guy’s and St Thomas’s NHS Foundation Trust – Otitis Externa

 

References

 

1.Patient info: patient leaflets – Cilodex ear drops

2.NHS Cornwall ICB Treatment Policies

 

 

Page Review Information

 

Review date	15 March 2024
Next review date	15 March 2026
Specialty Lead GP	Dr Laura Vines
Contributors	Venkat Reddy, ENT Consultant Surgeon Aileen Lambert, ENT Consultant Surgeon