Approach to managing acute diffuse otitis externa

Prescribe oral analgesics (eg paracetamol, NSAIDs) according to the severity of the patient’s pain – see Using analgesics to manage acute pain.

Note: Do not use oral antibiotic therapy for acute diffuse otitis externa.

Do not use oral antibiotic therapy for acute diffuse otitis externaRasheed, 2022Wang, 2018Roland, 2008. Use combination corticosteroid and antimicrobial ear drops; the choice depends on whether fungal infection (otomycosis) is suspected. For regimens, see:

It is not necessary to routinely perform culture to guide antimicrobial therapy.

Severe cases of acute diffuse bacterial otitis externa present with intense pain and complete occlusion of the external ear canal. If ear drops cannot be instilled because the canal is occluded, inserting a wick into the occluded ear canal can facilitate ear drop administration. If fever and extension of infection beyond the ear canal also occurs, consider treating as cellulitis and erysipelas.

Consider removal of discharge or other debris by dry aural toilet (mechanical suction or, under direct visualisation, cotton wool on a probe) if the expertise and equipment are available. The aim of aural toilet is to facilitate ear drop administration, but it may be uncomfortable and does not have strong evidence to support its use. Do not syringe the ear with water or other fluids.

Advise patients to keep the external ear canal as dry as possible during and for 2 weeks after treatment. To prevent water entry, the external ear canal should be occluded with earplugs (although canal tenderness may limit use), or a shower or bathing cap. Alternatively, a malleable, nonpermeable material (eg cotton wool with Vaseline, Blu Tack) can be used.

If the pain persists despite a normal canal appearance, consider noninfectious causes of pain (eg temporomandibular joint pain) or, in patients with diabetes or immune compromise, necrotising otitis externa.

Recurrent otitis externa is typically caused by dermatitis – see Preventing and managing recurrent diffuse otitis externa.

If inflammation of the external ear canal lasts for 3 months or longer, consider chronic otitis externa.