With pain

Background: Otitis externa is an inflammatory condition of the outer ear categorised by pain or itch. The pain can be severe. Itch is more suggestive of a fungal cause. There may be associated otorrhoea, external auditory canal oedema and resultant conductive hearing loss. 

How to manage:

Send an ear swab to guide future treatment if failure of initial therapy

Ensure patient keeps their ear dry, advise the use of cotton wool with Vaseline to prevent water ingress when in the bath or shower.

There is NO role for oral antibiotics for simple otitis externa

We suggest topical steroid and antibiotic drops (ciprofloxacin and dexamethasone) to reduce the ear canal skin inflammation and treat the infection

Ear calm spray can help relieve symptoms of itch (caution – may be uncomfortable on broken skin)

Referral guidance:

Emergency referral to ENT if significant pain or ear canal swollen shut by inflammation as may require microsuction and insertion of a pope wick to allow topical application of treatments

ENT referral on a routine basis if no improvement after 3 weeks

Cautions:

Some patients may be sensitive to agents within the topical treatments, which may present similarly to mild otitis externa. Stopping all therapy for a period of time to assess response may be helpful

Necrotising Otitis Externa (Skull Base Ostemomyelitis) can occur in immunosuppressed patients (older patient, diabetic patients, medications).  Red flag symptoms include pain out of proportion to clinical findings and facial palsy.  These patients require Emergency referral to ENT.

Ear canal malignancy is rare but should be considered in patients with presumed unilateral otitis externa that are not improving with topical treatments.

Background: Acute Otitis Media is a bacterial infection of the middle ear and commonly occurs after a viral URTI.  It is categorised by unilateral otalgia and hearing loss in the absence of discharge.  Discharge occurs with resolution of the pain when there is spontaneous rupture of the tympanic membrane.  The resultant perforation should seal without intervention.  Most cases should be managed within primary care.

Secondary care referral is not required unless complications or sepsis is suspected.

How to assess:

Examine the ear – if the tympanic membrane is normal then mastoiditis is unlikely

Examine the mastoid bone (posterior to ear) – does the pinna protrude forwards compared to the other side, is there erythema, is there fluctuance?

Referral guidance:

Oral antibiotics in accordance with NICE & local prescribing guidelines Infection Management in Adults, Primary Care, NHSGGC (166) and Recommendations: Otitis media (acute): antimicrobial prescribing, NICE

Emergency referral to ENT if concerned regarding mastoiditis

Complications:

Post-auricular lymphadenopathy can become tender and/or erythematous and so can occasionally be confused for mastoiditis.

Mastoiditis is a complication of acute otitis media. It presents with a history of otalgia and hearing loss from acute otitis media, followed by sepsis, pinna protrusion and pain over the mastoid process. Patients with suspected mastoiditis should be referred to ENT as an Emergency for consideration of imaging and/or surgical management.  However, if the tympanic membrane is normal, then the patient is unlikely to have acute mastoiditis. Another common cause of otalgia and post-auricular pain is otitis externa with post-auricular lymphadenopathy.