Document type
Clinical pathways
East and North Hertfordshire
Output type
Clinical Pathways
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 39ÂșC;
  • 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