RAG rating

n/a

Document type

Clinical pathways

Place

East and North Hertfordshire

Output type

Clinical Pathways

Pathway

Otitis Externa

Otitis Externa

Suspicion of necrotising otitis externa- emergency referral for admission:

• Otalgia and headache more severe than clinical signs would suggest;
• Refractory otitis externa with temperature over 39ºC;
• Severe nocturnal otalgia;
• Purulent otorrhoea;
• Presence of pseudomonas;
• Granulation tissue or exposed bone in the ear canal;
• Cranial nerve involvement e.g. facial nerve palsy.

High risk population groups include: elderly, patients with diabetes and immunocompromised patients.

Other Red Flags indicating emergency referral:

• Cellulitis spreading the face;
• Significant progression of otitis externa;
• Mastoiditis;
• Perichondritis.

Routine ENT referral:

• 3 x episodes in 6 months or 4 episodes in 12 months;
• Large or recurrent perforation;
• Protracted symptoms resistant to topical therapy;
• Suspected cholesteatoma;
• Chronic on-going infections interfering with hearing aid use.

Include in the referral:

• History of symptoms and associated symptoms;
• Examination of ear;
• Treatments tried duration, response and side-effects.

For urgent ENT referral or acute ENT clinic at Lister, contact on-call ENT SHO    

For Outpatient appointments: please use choose and book system/e-referral

Treatment options:

• Oral analgesia for pain
• Topical agents
• Oral agents (oral antibiotics rarely indicated)
• Consider cleaning ear canal

When referring for suspected chronic suppurative otitis media:

• Do not swab the ear (the usefulness of this is uncertain) or initiate treatment.
• Explain that a specialist will clean the ear, give antibiotics, and advise keeping the ear dry (for example swimming precautions).
• Explain that any hearing loss will usually return when the perforation heals, but a hearing test may be done in secondary care.

In cases of otitis externa:

• Cleanse the ear canal with gentle syringing/irrigation (if no appropriate provisions in primary care setting please refer via hospital switchboard ENT SHO for acute ENT clinic)
• Consider topical antibiotics and steroid drops
• Advise not to poke ear or let shampoo/soap into ear
• Screen for diabetes in at-risk group associated with otitis externa

For further information, see Priorities Forum statement Grommet insertion in adults