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Ear, nose and throat Skin and nail

Otitis externa

Last revised in September 2026

Otitis externa is inflammation of the external ear canal and is classified as acute - lasting 3 weeks or less or chronic - lasting longer than 3 months

Otitis externa: Summary

  • Otitis externa describes diffuse inflammation of the skin and subdermis of the external ear canal, which may also involve the pinna or tympanic membrane.
    • Acute otitis externa is inflammation of less than 6 weeks duration, typically caused by bacterial infection with Pseudomonas aeruginosa or Staphylococcus aureus.
    • Chronic otitis externa is inflammation which has lasted longer than 3 months and may be caused by fungal infection with Aspergillus species or Candida albicans.
    • Necrotizing (previously called 'malignant') otitis externa is a potentially life-threatening progressive infection of the external ear canal causing osteomyelitis of the temporal bone and adjacent structures.
  • Acute otitis externa may be associated with underlying skin conditions including contact dermatitis; acute otitis media; trauma to the ear canal; foreign body or obstruction in the ear canal; and water exposure.
  • Chronic otitis externa may also be associated with diabetes mellitus or other causes of immunocompromise; or fungal infection due to prolonged topical antibiotic or corticosteroid use.
  • Necrotizing otitis externa may be associated with diabetes mellitus or other causes of immunocompromise; older age; radiotherapy to the ear, head, or neck; and previous ear surgery or irrigation.
  • A diagnosis of otitis externa should be suspected if there is:
    • Acute — itch, pain, or discharge of the ear canal; hearing loss; tenderness of the tragus and/or pinna; red and oedematous ear canal; tympanic membrane erythema.
    • Chronic — itch in the ear, dry scaly skin or red moist skin in the ear canal, possible signs of fungal infection.
    • Necrotizing — unremitting pain, purulent ear discharge, systemic illness, hearing loss, granulation tissue in the ear canal, possible facial nerve palsy.
  • Assessment of suspected otitis externa includes:
    • Asking about the onset, nature, and severity of symptoms; impact on daily functioning; risk factors; previous episodes and treatments; previous ear surgery; associated comorbidities.
    • Examining the ear canal, pinna, and local lymph nodes for possible signs.
    • Arranging an ear swab for bacterial and fungal microscopy, culture, and sensitivity if there is treatment failure; severe, recurrent, or chronic infection; ear canal occlusion, or cellulitis beyond the ear canal.
  • Management of otitis externa includes:
    • Providing advice on sources of information and support.
    • Providing advice on self-care measures such as avoiding ear trauma; keeping the ear clean and dry; considering the use of over-the-counter acetic acid 2% ear drops or spray.
    • Managing any underlying causes or risk factors.
    • Advising on analgesia options.
    • Considering the need for 'aural toilet' if there is ear canal debris or exudate.
    • Considering prescribing a topical antibiotic or antifungal preparation, with or without corticosteroid, depending on clinical judgement.
    • Arranging follow up if there are persistent or severe symptoms; the person is immunocompromised; or there is ear canal stenosis or obstruction which is causing difficulty using topical treatment effectively.
    • Seeking specialist advice or arranging specialist referral, depending on clinical judgement.

Have I got the right topic?

From age 3 months onwards.

This CKS topic covers the diagnosis and management of acute and chronic otitis externa.

This CKS topic does not cover the use of microsuction or wick insertion in primary care, or the detailed specialist management of malignant otitis externa.

There are separate CKS topics on Boils, carbuncles, and staphylococcal carriage, Earwax, Otitis media - acute, and Otitis media with effusion.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

September 2026 — reviewed. A literature search was conducted in August 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The recommendations have been updated in line with current evidence in the literature. The term 'malignant' otitis extrena has been replced with necrotizing otitis externa which is the preferred term used in the ENT UK guideline. 

Previous changes

August 2025 — minor update. Reference to Otomize spray has been removed as the product has been discontinued. 

May 2024 — minor update. A typographical error has been corrected. 

February 2022 — minor update. Cetraxal® (ciprofloxacin 2 mg/mL ear drops solution in a single-dose container) and Cetraxal plus® added to the topical preparations table. Cilodex® removed and generic combined preparation ciprofloxacin and dexamethasone added. 

September to October 2021 — reviewed. A literature search was conducted in August 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The Scenario on Localized otitis externa has been removed, as content is covered in the CKS topic on Boils, carbuncles, and staphylococcal carriage. The recommendations have been updated in line with current evidence in the literature. The Prescribing information section has been updated, and information on oral flucloxacillin and clarithromycin has been removed, as oral antibiotics are not routinely needed in primary care for the management of uncomplicated acute otitis externa, in line with current evidence in the literature.

July 2020 — minor update. Typographical error corrected.

February 2018 — minor update. New product availability of Cetraxal® (ciprofloxacin 2mg/ml ear drops solution in a single-dose container) included.

September to October 2016 — reviewed. A literature search was conducted in September 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Minor structural changes have been made.

July 2015 — minor update. The information on the concurrent use of clarithromycin or erythromycin with statins has been clarified.

April 2015 — minor update. A link to the CKS topic on Analgesia - mild-to-moderate pain has been inserted.

April 2014 — minor update. The scenario on acute diffuse otitis externa has been split, for clarity, into a scenario on the initial management of diffuse otitis externa and a scenario on the management of treatment failure of diffuse otitis externa. Advice about avoiding swimming until any infection has been successfully treated has been added, and self-care advice has been included in all the management scenarios.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

August 2012 — reviewed. A literature search was conducted in August 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No major changes to clinical recommendations have been made.

July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency (MHRA). Prescriptions have been updated to reflect the revised dosing. Issued in July 2011.

June 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.

August to October 2010 — updated. Topical acetic acid 2% is now recommended for first-line use in cases of mild acute diffuse otitis externa (discomfort and/or itch; no pain, deafness, or discharge). Topical antibiotics, with or without a corticosteroid, are recommended for first-line use in more severe cases. The section has also been updated. Issued in November 2010.

March 2008 — minor typographical corrections.

July to October 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

October 2006 — minor update. Analgesia prescriptions updated to reflect new doses of ibuprofen for children as recommended by the British National Formulary. Issued in October 2006.

October 2005 — minor technical update. Issued in November 2005.

March 2004 — reviewed. Validated in May 2004 and issued in July 2004.

June 2001 — rewritten. Validated in July 2001 and issued in October 2001.

August 1998 — written, replacing previous guidance on Candidal otitis externa, Infective otitis externa and Other otitis externa.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 August 2026.

HTAs (Health Technology Assessments)

No new HTAs since 1 August 2026.

Economic appraisals

No new economic appraisals relevant to England since 1 August 2026.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 August 2026.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 August 2026.

New policies

No new national policies or guidelines since 1 August 2026.

New safety alerts

No new safety alerts since 1 August 2026.

Changes in product availability

No changes in product availability since 1 August 2026.

Goals and outcome measures

Goals

To support primary healthcare professionals to: 

  • Correctly diagnose otitis externa.
  • Offer appropriate management in primary care and follow up when required.
  • Advise on self-care measures to help symptom relief and prevent future episodes.
  • Arrange referral to an ear, nose, and throat (ENT) specialist when appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Otitis externa describes diffuse inflammation of the skin and subdermis of the external ear canal (auditory canal), which may also involve the pinna or tympanic membrane. It is also known as 'swimmer's ear' or 'tropical ear' [Rosenfeld, 2014; ENT UK, 2023].
    • A UK consensus document defines acute otitis externa as inflammation of less than 6 weeks duration [Smith, 2021].
      • Acute inflammation is typically caused by bacterial infection with Pseudomonas aeruginosa or Staphylococcus aureus [Rosenfeld, 2014; Wiegand, 2019].
    • Chronic otitis externa describes inflammation which has lasted for longer than 3 months [Rosenfeld, 2014; Barry, 2021].
      • Persistent inflammation may be caused by fungal infection, for example, due to Aspergillus species or Candida albicans [Rosenfeld, 2014; Wiegand, 2019].
  • Necrotizing otitis externa (previously called 'malignant' otitis externa) is a potentially life-threatening progressive infection of the external ear canal, which may spread to cause osteomyelitis of the temporal bone and adjacent structures [Rosenfeld, 2014; Wiegand, 2019; Hopkins, 2020].
    • It is commonly caused by infection with Pseudomonas aeruginosa.

How common is it?

  • There is limited epidemiological data available on the prevalence of otitis externa in primary care.
    • A UK survey of age- and sex-stratified primary care data from the General Practice Research Database in 1997 found a total of 30,412 patients with a diagnosis of otitis externa [Rowlands, 2001]:
      • Otitis externa was a common diagnosis in all age groups, and was more common in females than in males up to the age of 65 years, with prevalence estimates of 1.3% and 1.16% for females and males, respectively, in the 12-month study period.
      • 21% of participants reported more than one episode of otitis externa, and 7% reported three or more episodes in the 12-month study period.
      • Prevalence increased at the end of the summer, especially in those aged 5–19 years.
    • A US clinical guideline notes a lifetime prevalence of 10% for acute otitis externa [Rosenfeld, 2014; Kirubalingam, 2026].
    • A small prospective UK regional study in primary care (n = 48) from 1990 to 1991 reported:
      • About 25% of participants with otitis externa had had persistent or recurrent symptoms for at least 6 months [Agius, 1992].
  • A substantial body of evidence indicates a rising incidence of necrotising otitis externa (NOE) [Kong, 2025].
    • Between 1 April 2002 and 31 March 2024, there were a total of 15,449 reported NOE cases accounting for 142,002 hospital bed days.
    • Of these patients, 71.2% were male, and 28.8% were female.
    • The mean hospital stay was 15.9 days (range 11.7–18.5 days).
    • Admission data show a gradual increase in reported cases annually from 2002–2003 to 2014–2015, followed by a marked rise between 2014–2015 and 2017–2018, and several peaks and troughs between 2017-–2018 and 2023–2024, with an overall continued rise in cases per year.
      • The rise is thought to be a result of the increasing incidence of diabetes and the growing elderly population.

What are the risk factors?

  • Acute otitis externa can be caused by:
    • Skin conditions — conditions such as eczema, psoriasis, and seborrhoeic dermatitis may produce debris and skin breakdown in the ear canal, which can encourage infection [Rosenfeld, 2014; Wipperman, 2014; Wiegand, 2019].
    • Acute otitis media — purulent middle ear secretions may enter the external ear canal if there is tympanic membrane perforation or a tympanostomy tube in situ [Rosenfeld, 2014].
    • Contact dermatitis — this is caused by a local irritant or allergen, such as contact sensitivity to topical aminoglycosides such as neomycin or other topical antibiotics or corticosteroids, shampoo, detergents, plastics, and chemicals used in hearing aid moulds, silicone ear plugs, or metals such as nickel or silver earrings [Rosenfeld, 2014; Wipperman, 2014; Wiegand, 2019].
    • Trauma to the ear canal — this may be from ear cleaning (which reduces earwax, which is a natural barrier to moisture and infection, as it creates a slightly acidic pH in the ear canal, inhibiting ear infection) [Rosenfeld, 2014; Wipperman, 2014; Wiegand, 2019; RCGP, 2026]. In addition, the use of cotton buds, hearing aids, ear plugs, scratching, or instrumentation (including ear syringing) can cause local trauma [Barry, 2021].
    • Foreign body in the ear and the use of hearing aids or ear plugs [Rosenfeld, 2014; Wiegand, 2019].
    • Water exposure — factors such as high temperature and/or humidity, perspiration, and swimming (especially in polluted water) may contribute. Water exposure alters the ability of earwax to create an acidic pH in the ear canal which usually inhibits infection [Rosenfeld, 2014; Wiegand, 2019; RCGP, 2026].
    • Ear canal obstruction — due to debris or inflammation from skin conditions or excess earwax production [Wiegand, 2019].
  • Chronic otitis externa can be caused by:
    • Skin conditions — conditions such as eczema, psoriasis, and seborrhoeic dermatitis may produce debris and skin breakdown in the ear canal, which can encourage infection [Rosenfeld, 2014; Wipperman, 2014; Wiegand, 2019].
    • Uncontrolled diabetes mellitus or other causes of immunocompromise [Rosenfeld, 2014; Wiegand, 2019].
    • Contact dermatitis — this is caused by a local irritant or allergen, such as contact sensitivity to topical aminoglycosides such as neomycin or other topical antibiotics or corticosteroids, shampoo, detergents, plastics, and chemicals used in hearing aid moulds, silicone ear plugs, or metals such as nickel or silver earrings [Rosenfeld, 2014; Wipperman, 2014; Wiegand, 2019].
    • Fungal infection — ear canal flora may be modified by long-term topical antibiotic or corticosteroid use, which may predispose to secondary fungal overgrowth [Rosenfeld, 2014; Wiegand, 2019; Ellis, 2024].
    • Bacterial infection — low-grade, persistent infection causes thickening of the ear canal skin, loss of normal skin structure, and reduced protective earwax production [Wipperman, 2014].
  • Necrotizing otitis externa can be caused by:

What are the complications?

Possible complications of otitis externa include:

What is the prognosis?

  • Acute diffuse otitis externa.
    • Symptoms of acute otitis externa usually improve within 48–72 hours of initiation of treatment.
    • Between 65–90% of people with uncomplicated diffuse otitis externa have clinical resolution within 7–10 days, regardless of the topical drug treatment used.
  • Chronic otitis externa.
    • The lumen of the ear canal may progressively narrow and, after several years, may become completely stenosed, resulting in hearing loss in the affected ear.
  • Necrotizing otitis externa.
    • This can be life-threatening. Temporal bone osteomyelitis is associated with a mortality rate of 10–21%.

[Rosenfeld, 2014; Wiegand, 2019; Ellis, 2024]

Diagnosis of otitis externa

Diagnosis

When should I suspect acute otitis externa?

Suspect a diagnosis of acute otitis externa if a person presents with:

  • At least one typical symptom (usually rapid-onset within 48 hours):
    • Itch of the ear canal.
    • Ear pain and tenderness of the tragus and/or pinna (often severe), with possible jaw pain.
    • Ear discharge.
    • Hearing loss due to ear canal occlusion (less common).
  • At least two typical signs:
    • Tenderness of the tragus and/or pinna.
    • The ear canal is red and oedematous, and there may be debris and ear discharge contributing to swelling and canal occlusion.
    • Tympanic membrane erythema (may be difficult to visualize if the ear canal is narrowed or filled with debris).
    • Cellulitis of the pinna and adjacent skin. See the CKS topic on Cellulitis - acute for more information.
    • Conductive hearing loss (less common).
    • Tender regional lymphadenitis (less common).

When should I suspect chronic otitis externa?

Suspect a diagnosis of chronic otitis externa if a person presents with:

  • Typical symptoms:
    • Constant itch in the ear.
    • Mild discomfort or pain (rare).
  • Typical signs:
    • Lack of earwax in the external ear canal.
    • Dry, scaly skin in the ear canal, which varies in thickness but often results in at least partial canal stenosis; or red, moist skin in the ear canal.
    • Fluffy, cotton-like debris, hyphae, or dots of black debris may be seen in the ear canal if there is a fungal infection.
    • Conductive hearing loss.

When should I suspect necrotizing otitis externa?

Suspect a diagnosis of necrotizing otitis externa if a person presents with:

  • Typical symptoms:
    • Unremitting disproportionate ear pain, headache, purulent otorrhoea, fever, or malaise.
    • Vertigo.
    • Profound conductive hearing loss.
  • Typical signs:
    • Systemically unwell and high fever.
    • Granulation tissue seen on the floor of the ear canal and at the bone-cartilage junction; exposed bone in the ear canal.
    • Ipsilateral facial nerve palsy.

Basis for recommendation

The information on diagnosis is based on the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS) clinical practice guideline Acute otitis externa [Rosenfeld, 2014], a UK consensus document Acute otitis externa: consensus definition, diagnostic criteria and core outcome set development [Smith, 2021], an ENT UK Global guideline on Otitis externa [ENT UK, 2023], a guideline on the management of malignant otitis externa [Hopkins, 2020], the RCGP learning document Paediatric Hearing - Otitis Externa (Swimmers Ear) [RCGP, 2026] and expert opinion in review articles on otitis externa [Wipperman, 2014; Wiegand, 2019; Barry, 2021; Ellis, 2024].

How should I assess a person with suspected otitis externa?

If a person has suspected otitis externa:

  • Ask about:
    • The onset, nature, and severity of symptoms, such as:
      • Pain or tenderness on moving the ear (tragus or pinna) or jaw.
      • Ear discharge.
      • Itch in the ear canal.
      • Fever.
      • Hearing loss (conductive).
    • Impact on daily functioning and quality of life.
    • Any possible causes or risk factors, including recent ear trauma, use of hearing aids or ear plugs, or a history of head or neck radiotherapy.
    • Any previous episodes and topical or oral treatments used.
    • Any previous ear surgery, perforation of the tympanic membrane, and/or tympanostomy tube insertion within the previous year.
    • Any history of allergic or irritant contact dermatitis. See the CKS topic on Dermatitis - contact for more information.
    • Any comorbidities such as diabetes mellitus or other causes of immunocompromise. See the CKS topics on Diabetes - type 1 and Diabetes - type 2 for more information.
  • Examine the person's ears, starting with the unaffected or less affected ear:
    • Assess the ear canal, tympanic membrane, pinna, auricular, and cervical lymph nodes for possible signs:
      • Red, oedematous ear canal, which may be narrowed and obscured by debris.
      • Ear discharge (serous or purulent).
      • Signs of fungal infection (such as white strands of Candida, or small black or white balls of Aspergillus).
      • Regional lymphadenopathy.
      • Cellulitis spreading beyond the ear. See the CKS topic on Cellulitis - acute for more information.
    • Assess for a perforation of the tympanic membrane, including a tympanostomy tube in situ.
    • Assess the surrounding skin for associated skin disorders suggesting a possible underlying cause or alternative condition.
    • Note: it can be difficult to adequately visualize the tympanic membrane on initial presentation.
  • Most cases of otitis externa do not require culture and sensitivities. Consider arranging an ear swab for bacterial and fungal microscopy, culture, and sensitivity if there is:
    • Treatment failure. See the section on Treatment failure for more information.
    • Severe, recurrent, or chronic otitis externa.
    • Ear canal occlusion due to swelling and debris, causing difficulty using topical treatment effectively.
    • Suspected spread of infection beyond the external ear canal.

Basis for recommendation

The recommendations on assessment are largely based on the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS) clinical practice guideline Acute otitis externa [Rosenfeld, 2014], a UK consensus document Acute otitis externa: consensus definition, diagnostic criteria and core outcome set development [Smith, 2021], an ENT UK global guideline [ENT UK, 2023], the RCGP learning document Paediatric Hearing - Otitis Externa (Swimmers Ear) [RCGP, 2026] and expert opinion in review articles on otitis externa [Wipperman, 2014; Wiegand, 2019; Barry, 2021] and on the use of ear swabs in otitis externa [Llor, 2014; ].

Clinical features on history taking

  • The recommendations on history taking are based on the AAO-HNS clinical practice guideline [Rosenfeld, 2014], the UK consensus document [Smith, 2021], and the ENT UK global guideline [ENT UK, 2023].
    • The presence of risk factors may affect the prognosis of acute otitis externa, and a history of head and neck radiotherapy may increase the need for systemic antibiotic treatment [Rosenfeld, 2014; ENT UK, 2023].
    • A history of previous ear surgery or perforation of the tympanic membrane may affect the choice of treatment used, as preparations such as topical aminoglycosides are potentially ototoxic and increase the risk of hearing loss. The US clinical practice guideline notes limited evidence in clinical studies that hearing loss does not occur after a single short course of topical treatment [Rosenfeld, 2014].
    • The recommendation to ask about tympanostomy tube insertion within the previous year is based on the fact that usually within this timescale there is tube extrusion and tympanic membrane closure, although this cannot be assumed [Rosenfeld, 2014].
    • The recommendation to ask about comorbidities such as diabetes mellitus or other causes of immunocompromise is based on the fact these conditions may affect the prognosis of acute otitis externa. Affected people are at increased risk of fungal infection and/or necrotizing otitis externa, and are more likely to need systemic antibiotics for the treatment of acute otitis externa [Rosenfeld, 2014; ENT UK, 2023].

Clinical features on examination

  • The recommendations on examination are based on the AAO-HNS clinical practice guideline [Rosenfeld, 2014], the UK consensus document [Smith, 2021], the RCGP learning document Paediatric Hearing - Otitis Externa (Swimmers Ear) [RCGP, 2026][RCGP, 2026][RCGP, 2026] and expert opinion in review articles [Walton, 2012; Wiegand, 2019; Barry, 2021].
    • The recommendation to examine both ears, starting with the lesser affected is based on expert opinion in a review article [Barry, 2021].
    • The recommendation to assess for a perforation of the tympanic membrane, including a tympanostomy tube in situ, is based on the fact this may affect the prognosis of acute otitis externa [Rosenfeld, 2014].
    • The information that it can be difficult to visualize the tympanic membrane initially is based on expert opinion in review articles [Walton, 2012; Wiegand, 2019; Barry, 2021].

When to arrange an ear swab

  • The recommendations on when to arrange an ear swab are based on the AAO-HNS clinical practice guideline [Rosenfeld, 2014], the UK consensus document [Smith, 2021], and expert opinion in review articles [Llor, 2014; Wipperman, 2014].
    • The presence of cellulitis spreading beyond the external ear canal may indicate the need for systemic antibiotics [Rosenfeld, 2014].
    • Expert opinion in a review article notes that ear swab cultures may reflect commensal or colonizing microorganisms such as Staphylococcus epidermidis and Staphylococcus auricularis, enterococci, and Proteus species, which are not contributing to infection and should not be treated [Llor, 2014].

What else might it be?

Other conditions that may present similarly to otitis externa include:

  • Acute otitis media — may present with an erythematous tympanic membrane and ear discharge (particularly if a tympanostomy tube is in situ). See the CKS topic on Otitis media with effusion for more information.
  • Foreign body in the ear (especially in children) may present with purulent ear discharge and pain.
  • Impacted earwax — may cause pain and hearing loss. See the CKS topic on Earwax for more information.
  • Skin conditions — such as contact dermatitis, eczema, fungal skin infection, psoriasis, seborrhoeic dermatitis, erysipelas, and discoid lupus erythematosus involving the ear canal. See the CKS topics on Dermatitis - contact, Eczema - atopic, Fungal skin infection - body and groin, Psoriasis, and Seborrhoeic dermatitis for more information.
  • Referred pain — may originate from the teeth, sphenoidal sinus, neck, or throat. See the CKS topics on Dental abscess, Gingivitis and periodontitis, Sinusitis, and Sore throat - acute for more information.
  • Cholesteatoma — causes persistent or recurrent ear discharge and fullness, but is typically painless. There may be a perforated tympanic membrane, retraction pocket in the tympanic membrane, and granulation tissue, which may mimic malignant otitis externa. See the CKS topic on Cholesteatoma for more information.
  • Mastoiditis — may present with systemic illness, fever, marked hearing loss, and mastoid tenderness or swelling.
  • Ramsay Hunt syndrome — a form of herpes zoster affecting the facial nerve, which may present with severe pain, vesicles on the external ear canal and posterior pinna, facial paralysis, loss of taste on the anterior two-thirds of the tongue, and decreased lacrimation on the involved side. See the CKS topic on Shingles for more information.
  • Barotrauma — such as in divers, recent air travel, or recent ear trauma.
  • Malignancy — squamous cell carcinoma of the ear canal can present similarly to malignant otitis externa, with abnormal tissue growth in the ear canal or bloody ear discharge.

Basis for recommendation

The information on differential diagnosis is largely based on the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS) clinical practice guideline Acute otitis externa [Rosenfeld, 2014], a guideline on the management of malignant otitis externa [Hopkins, 2020], and expert opinion in review articles on otitis externa [Wiegand, 2019; Barry, 2021; Jackson, 2023; Ellis, 2024] and on the use of ear swabs in otitis externa [Llor, 2014].

Management

Scenario: Acute otitis externa

From age 3 months onwards.

How should I manage a person with acute otitis externa?

If a person presents with acute otitis externa:

  • Provide advice on sources of information and support, such as:
  • Provide advice on self-care measures for symptom relief and to reduce the risk of recurrent infection.
    • Avoid damage to the external ear canal:
      • Troublesome earwax should be removed safely to avoid damaging the ear canal. Cotton buds or other objects should not be used to clean the ear canal.
    • Keep the ears clean and dry.
      • Avoid swimming and water sports for at least 7–10 days during treatment.
      • Use ear plugs and/or a tight-fitting cap when swimming.
      • Keep shampoo, soap, and water out of the ear when bathing and showering, for example, by inserting ear plugs or cotton wool (with petroleum jelly).
      • Consider using a hair dryer (at the lowest heat setting) to dry the ear canal after hair washing, bathing, or swimming.
    • Consider use of over-the-counter acetic acid 2% ear drops or spray (for people aged 12 years and older) morning, evening, and after swimming, showering, or bathing, for a maximum of 7 days. See the section on Available preparations in Prescribing information for more information on other available antiseptic and astringent ear preparations.
  • Manage any underlying causes or risk factors including associated skin conditions, where possible.
    • If the person is allergic or has contact sensitivity to ear drops such as neomycin, ear plugs, hearing aids, or earrings, they should avoid use, or use alternatives where available (such as hypoallergenic hearing aids).
  • Advise on options for analgesia such as paracetamol or ibuprofen for symptom relief, if needed.
  • Consider cleaning the external auditory canal ('aural toilet'), to enable topical treatments to be applied effectively. Options include:
    • Dry swabbing of secretions.
    • Ear irrigation to remove debris, earwax, and exudate, if the tympanic membrane is visualized and intact and the person is not immunocompromised.
  • Consider prescribing a topical antibiotic preparation with or without a topical corticosteroid for 7–14 days, depending on clinical judgement and symptom response.
    • The choice of drug treatment should be guided by personal preference, risk of adverse effects including ototoxicity, cost, dosing frequency, and whether the tympanic membrane is intact (if visualized).
    • An additional topical corticosteroid preparation may be beneficial if there is significant inflammation, erythema, and oedema in the ear canal.
    • Advise on how to administer ear drops correctly.
    • See the section on Topical ear preparations in Prescribing information for more information on available preparations, how to administer, and contraindications to use.
  • Consider prescribing an oral antibiotic if the person is immunocompromised, there is severe infection, or there is spread beyond the external ear canal to adjacent tissues, depending on clinical judgement. See the CKS topic on Cellulitis - acute for more information on how to diagnose cellulitis.
  • Arrange follow up to reassess the person if:
    • Symptoms are not improving within 48–72 hours of starting initial treatment.
    • Symptoms have not fully resolved after 2 weeks of starting initial treatment.
    • Symptoms are severe and/or there is cellulitis spreading beyond the external ear canal. See the CKS topic on Cellulitis - acute for more information.
    • The person is immunocompromised and at risk of severe infection, depending on clinical judgement.
    • There is ear wax impaction or stenosis of the ear canal which prevents the tympanic membrane being visualized, to check for an alternative cause for symptoms.

Basis for recommendation

The recommendations on initial management are based on the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS) clinical practice guideline Acute otitis externa [Rosenfeld, 2014], the ENT UK global guideline document [ENT UK, 2023], a guideline on the management of malignant otitis externa [Hopkins, 2020], the RCGP learning document Paediatric Hearing - Otitis Externa (Swimmers Ear)[RCGP, 2026], and expert opinion in review articles on otitis externa [Walton, 2012; Wipperman, 2014; Wiegand, 2019; Barry, 2021; Ellis, 2024] and on the use of ear swabs in otitis externa [Llor, 2014].

Advising on self-care measures
  • The recommendations on avoiding damage to the external ear canal are based on the US clinical practice guideline [Rosenfeld, 2014] and expert opinion in a review article [Wipperman, 2014].
  • The recommendations to keep the ears clean and dry are based on the guidelines [Rosenfeld, 2014; ENT UK, 2023], the RCGP learning document Paediatric Hearing - Otitis Externa (Swimmers Ear) [RCGP, 2026] and expert opinion in a review article [Walton, 2012].
    • The US clinical practice guideline emphasizes the importance of strategies to reduce water accumulation and moisture retention in the ear canal, and provide a healthy skin barrier.
  • The recommendation to consider use of over-the-counter acetic acid 2% ear drops or spray is based on the US clinical practice guideline [Rosenfeld, 2014], the ENT UK Global guideline [ENT UK, 2023], the manufacturers' Summary of Product Characteristics [EMC, 2025], and expert opinion in review articles [Walton, 2012; Wiegand, 2019; Ellis, 2024].
    • Topical antiseptics such as acetic acid have broad-spectrum efficacy, and cause a reduction in pH which inhibits bacterial growth and allows more rapid healing [Wiegand, 2019].
Managing underlying causes or risk factors
  • The recommendation to manage underlying causes is based on the US clinical practice guideline [Rosenfeld, 2014], the ENT UK Global guideline [ENT UK, 2023], and expert opinion in a review article [Wipperman, 2014].
Advising on analgesia options
  • The recommendation to offer analgesia is based on the US clinical practice guideline [Rosenfeld, 2014], the ENT UK Global guideline [ENT UK, 2023], the RCGP learning document Paediatric Hearing - Otitis Externa (Swimmers Ear)[RCGP, 2026] and expert opinion in review articles [Wipperman, 2014; Wiegand, 2019; Ellis, 2024].
    • The pain caused by acute otitis externa can be intense and severe, because 'the highly sensitive periosteum of the underlying bone is in close proximity to the ear canal skin, especially in the deeper portion of the canal', and this is usually involved in the inflammatory process [Rosenfeld, 2014; Wiegand, 2019].
Arranging 'aural toilet'
  • The recommendation to consider dry swabbing of secretions is based on the US clinical practice guideline [Rosenfeld, 2014] and expert opinion in review articles [Wipperman, 2014; Barry, 2021; Ellis, 2024].
    • Aural toilet is important to maximize the efficacy of topical treatment, allowing it to penetrate the ear canal and reach the site of infection [Rosenfeld, 2014].
  • The recommendation to consider ear irrigation is extrapolated from the US clinical practice guideline [Rosenfeld, 2014], a guideline on the management of malignant otitis externa [Hopkins, 2020], and expert opinion in review articles [Wipperman, 2014; Wiegand, 2019; Barry, 2021].
    • Ear exudate may contain toxins that sustain the inflammatory process, and debris may also reduce or prevent the effective delivery of topical treatment [Wiegand, 2019].
    • The US clinical practice guideline notes that there is an increased risk of developing malignant otitis externa if ear irrigation is performed in a person who is immunocompromised [Rosenfeld, 2014; Wipperman, 2014; Hopkins, 2020]. In addition, CKS notes that expert opinion in a review article does not recommend ear syringing for people with acute otitis externa, as this may be very painful [Barry, 2021].
Prescribing a topical ear preparation
  • The recommendations on choice of topical ear preparations are based on the US clinical practice guideline [Rosenfeld, 2014], the ENT UK Global guideline [ENT UK, 2023], the RCGP learning document Paediatric Hearing - Otitis Externa (Swimmers Ear) [RCGP, 2026] and expert opinion in review articles [Wipperman, 2014; Wiegand, 2019; Ellis, 2024].
    • Both guidelines recommend topical antibiotics first line and note that these provide a high local concentration of drug in the ear canal which improves efficacy over placebo in randomized trials. Topical therapy avoids prolonged exposure of bacteria to subtherapeutic concentrations of antibiotic, with associated reduced likelihood of developing bacterial resistance.
    • There is evidence from multiple meta-analyses that there was no difference in clinical outcomes for different quinolone or non-quinolone antibiotic preparations, antibiotics versus antiseptic preparations, or monotherapy or combined therapy with a topical corticosteroid preparation [Di Traglia, 2023]. In particular, antibiotic eardrops containing quinolones (ciprofloxacin), aminoglycosides (neomycin), or polymyxins (polymyxin B) have been studied and found to provide more rapid symptom relief and cure, and to lower recurrence rates compared with placebo. The US guideline does, however, note that multiple included studies showed 'large heterogeneity for the pooled estimate of treatment effect', and limited generalizability to the primary care setting [Rosenfeld, 2014].
    • The guidelines recommend avoiding ototoxic topical preparations such as those containing aminoglycosides or alcohol if there is evidence of tympanic membrane perforation. The US guideline cites inconsistent evidence in the literature regarding the benefits of adding in a topical corticosteroid preparation to help reduce inflammation and improve pain relief [Rosenfeld, 2014].
    • Oral antibiotics have a limited role in treating uncomplicated acute otitis externa, as they are less potent at treating the site of infection compared with topical preparations, and the clinical guideline found no data to support their routine use. In addition, oral antibiotics have an increased risk of adverse effects and increased likelihood of bacterial resistance [Rosenfeld, 2014; Wipperman, 2014; Wiegand, 2019; ENT UK, 2023; Ellis, 2024]. This is supported by a UK survey of primary care data which found rates of ongoing symptoms at 28 days, and to a lesser extent recurrence of symptoms after 28 days, were higher in people prescribed oral antibiotics [Rowlands, 2001].
  • The recommendation to consider the addition of a topical corticosteroid preparation is based on the US clinical practice guideline [Rosenfeld, 2014] and expert opinion in review articles [Wipperman, 2014; Wiegand, 2019; Di Traglia, 2023].
  • The recommendation to show how to administer ear drops is based on the US clinical guideline [Rosenfeld, 2014] and expert opinion in review articles [Wipperman, 2014; Wiegand, 2019].
    • A correct ear drop technique improves treatment efficacy and compliance [Rosenfeld, 2014]. Conversely, a poor technique can lead to treatment failure [Wipperman, 2014].
Prescribing oral antibiotics
Arranging follow up
  • The recommendations on when to arrange follow up are based on the US clinical practice guideline [Rosenfeld, 2014], the ENT UK Global guideline [ENT UK, 2023], and expert opinion in review articles [Barry, 2021; Ellis, 2024].
    • Symptoms of uncomplicated acute otitis externa should improve within 48–72 hours of starting appropriate topical antibiotic therapy, but may persist for up to 2 weeks. If symptoms do not improve rapidly, additional treatment may be needed such as 'aural toilet' or ear wick insertion, or consideration of an alternative diagnosis [Rosenfeld, 2014; ENT UK, 2023].
    • If there are severe symptoms and/or cellulitis spreading beyond the external ear canal, oral antibiotics may be needed [Rosenfeld, 2014].
    • People who are immunocompromised are at increased risk of developing fungal infection or malignant otitis externa [Rosenfeld, 2014; ENT UK, 2023].
    • The recommendation if the ear canal is occluded is based on expert opinion in a review article [Barry, 2021].

How should I manage treatment failure of acute otitis externa?

If a person has had initial management of acute otitis externa and symptoms persist:

  • Assess for associated or alternative conditions, which may be causing ongoing symptoms.
  • Reassess for any underlying causes or risk factors including associated skin conditions, where possible.
  • Ensure the person is following advice on self-care measures. See the section on Initial management for more information.
  • Ensure the person is using any topical drug treatment correctly.
    • Consider switching from an ear drop to an ear spray preparation (or vice versa), depending on clinical judgement.
    • If contact sensitivity to neomycin or another aminoglycoside ear drop is suspected, consider switching to a preparation which does not contain an aminoglycoside.
  • Re-examine the person.
    • Assess for ear canal occlusion due to ear discharge, swelling, or debris, which may stop topical treatment working effectively.
    • Assess for signs of fungal ear infection, foreign body, tympanic membrane perforation, or middle ear disease, and treat appropriately.
    • Assess for signs of systemic illness or infection spreading beyond the external ear canal. See the CKS topic on Cellulitis - acute for more information.
      • Consider prescribing an oral antibiotic if infection has spread beyond the external ear canal to adjacent tissues. See the section on Initial management for more information.
  • Consider cleaning the external ear canal ('aural toilet') to enable topical treatments to be applied effectively. Options include:
    • Dry swabbing of secretions.
    • Ear irrigation to remove debris, earwax, and exudate, if the tympanic membrane is visualized and intact.
  • Consider arranging an ear swab for bacterial and fungal microscopy, culture, and sensitivity, and arrange treatment depending on the result.
    • See the section on Assessment for more information.
  • Consider the need to seek specialist advice or arrange specialist referral.

Basis for recommendation

The recommendations on managing treatment failure are based on the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS) clinical practice guideline Acute otitis externa [Rosenfeld, 2014], a UK consensus document Acute otitis externa: consensus definition, diagnostic criteria and core outcome set development [Smith, 2021], the ENT UK Global guideline document [ENT UK, 2023], a guideline on the management of malignant otitis externa [Hopkins, 2020], and expert opinion in review articles on otitis externa [Wipperman, 2014; Wiegand, 2019; Barry, 2021; Ellis, 2024], and on the use of ear swabs in otitis externa [Llor, 2014].

Assessing for associated or alternative conditions
Reassessing for underlying causes or risk factors
Advising on self-care measures
Checking compliance with topical drug treatment
  • This recommendation is based on guidelines [Rosenfeld, 2014; ENT UK, 2023] and expert opinion in review articles [Llor, 2014; Wipperman, 2014; Ellis, 2024].
    • A correct ear drop technique improves treatment efficacy and compliance [Rosenfeld, 2014]. Conversely, a poor technique can lead to treatment failure [Wipperman, 2014].
    • The recommendation to switch between ear drop and ear spray preparations is extrapolated from the US clinical practice guideline, and is also pragmatic, based on what CKS considers to be sensible clinical practice.
    • The recommendation to switch to a non-aminoglycoside ear drop if contact sensitivity is suspected is based on the US clinical practice guideline [Rosenfeld, 2014].
 Re-examining the person
  • The recommendations to re-examine the person are based on the guidelines [Rosenfeld, 2014; ENT UK, 2023] and expert opinion in review articles [Wipperman, 2014; Wiegand, 2019; Ellis, 2024].
    • The US clinical practice guideline notes that fungal infection should be suspected if symptoms fail to respond to initial topical antibiotic therapy.
    • The recommendation to consider the use of oral antibiotics if there is spread beyond the external ear canal to adjacent tissues is based on the US clinical practice guideline and expert opinion in a review article [Wiegand, 2019].
Arranging 'aural toilet'
  • The recommendation to consider dry swabbing of secretions is based on the guidelines [Rosenfeld, 2014; ENT UK, 2023] and expert opinion in review articles [Wipperman, 2014; Barry, 2021; Ellis, 2024].
    • Aural toilet is important to maximize the efficacy of topical treatment, allowing it to penetrate the ear canal and reach the site of infection [Rosenfeld, 2014].
  • The recommendation to consider ear irrigation is extrapolated from the US clinical practice guideline [Rosenfeld, 2014], a guideline on the management of otitis externa [Hopkins, 2020], and expert opinion in review articles [Wipperman, 2014; Wiegand, 2019; Barry, 2021].
    • Ear exudate may contain toxins that sustain the inflammatory process, and debris may also reduce or prevent the effective delivery of topical treatment [Wiegand, 2019].
    • The US clinical practice guideline notes that there is an increased risk of developing malignant otitis externa if ear irrigation is performed in a person who is immunocompromised [Rosenfeld, 2014; Wipperman, 2014; Hopkins, 2020]. In addition, CKS notes that expert opinion in a review article does not recommend ear syringing for people with acute otitis externa, as this may be very painful [Barry, 2021].
Arranging an ear swab
  •   The recommendation to consider arranging an ear swab is extrapolated from the guidelines [Rosenfeld, 2014; ENT UK, 2023] , a UK consensus document [Smith, 2021], a guideline on malignant otitis externa [Hopkins, 2020], and expert opinion in review articles [Llor, 2014; Wiegand, 2019; Barry, 2021; Ellis, 2024].
    • Treatment failure may be due to 'microbiological factors', such as fungal infection, resistant bacteria, or unusual causes of infection that need targeted topical or systemic therapy. Fungal infection can cause persistent infection in the ear canal if flora is altered following topical antibiotic therapy [Rosenfeld, 2014; ENT UK, 2023].

When should I seek specialist advice or refer for acute otitis externa?

  • Arrange emergency hospital admission or urgent referral to an ear, nose, and throat (ENT) specialist if:
  • Seek specialist advice or arrange referral to an ENT specialist, the urgency depending on clinical judgement, if:
    • Symptoms persist despite optimal management in primary care. See the section on Treatment failure for more information.
    • There is severe infection not responding to management in primary care.
    • The person is elderly, has poorly controlled diabetes mellitus or another cause of immunocompromise, depending on clinical judgement.
    • There is external ear canal occlusion due to ear discharge, swelling, or debris which is stopping topical treatment from working effectively.
      • Specialist 'aural toilet' including microsuction, ear wick insertion, or use of systemic antibiotics may be needed.
    • There is cellulitis extending beyond the external ear canal which cannot be managed in primary care. See the CKS topic on Cellulitis - acute for more information.
      • Systemic antibiotics may be needed, following specialist advice.
  • Consider referral to a dermatology specialist if contact sensitivity to neomycin or another aminoglycoside ear preparation, ear plugs, hearing aids, or earrings, is suspected.
    • Patch testing to confirm contact sensitivities may be needed.

Basis for recommendation

The recommendations on referral are based on the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS) clinical practice guideline Acute otitis externa [Rosenfeld, 2014], the ENT UK Global guideline on Otitis externa [ENT UK, 2023], a primary care study When to refer: validating the Evidence-based Acute otitis externa Referral Score (EARS). Our experience of 287 cases of otitis externa in primary care [Selwyn, 2019], a guideline on the management of malignant otitis externa [Hopkins, 2020], and expert opinion in review articles on otitis externa [Walton, 2012; Wipperman, 2014; Wiegand, 2019; Barry, 2021; Ellis, 2024] and on the use of ear swabs in otitis externa [Llor, 2014].

Arranging hospital admission or urgent ENT referral
  • The recommendations on when to arrange emergency hospital admission or urgent referral are based on the primary care study [Selwyn, 2019] and expert opinion in a review article [Barry, 2021]. They are also pragmatic, based on what CKS considers to be good clinical practice.
    • A multicentre, retrospective analysis of primary care records of 239 patients with otitis externa was used to assess the validity of the 'Evidence-based Acute otitis externa Referral Score (EAR Score)', a risk stratification score designed to help identify patients at higher risk of complications needing specialist referral [Selwyn, 2019].
      • The scoring system assessed clinical domains of risk factors (such as uncontrolled diabetes mellitus or other causes of immunocompromise); duration of treatment (including uncontrolled symptoms during treatment or persistent symptoms at 14 days after treatment started); and red flags (including complications). It had a sensitivity of 100%, specificity of 90%, and negative predictive value of 100%.
Seeking specialist advice or arranging ENT referral
  • The recommendations on when to seek specialist advice or arrange referral are extrapolated from the primary care study on acute otitis externa [Selwyn, 2019], on current guidelines [Rosenfeld, 2014; ENT UK, 2023], a guideline on malignant otitis externa [Hopkins, 2020], and expert opinion in review articles [Walton, 2012; Wipperman, 2014; Wiegand, 2019; Ellis, 2024].
    • A multicentre, retrospective analysis of primary care records of 239 patients with otitis externa was used to assess the validity of the 'Evidence-based Acute otitis externa Referral Score (EAR Score)', a risk stratification score designed to help identify patients at higher risk of complications needing specialist referral [Selwyn, 2019].
      • The scoring system assessed clinical domains of risk factors (such as uncontrolled diabetes mellitus or other causes of immunocompromise); duration of treatment (including uncontrolled symptoms during treatment or persistent symptoms at 14 days after treatment started); and red flags (including complications). It had a sensitivity of 100%, specificity of 90%, and negative predictive value of 100%.
      • It recommends ENT referral if there are recurrent episodes of acute otitis externa, persistent symptoms despite adequate treatment, and/or the presence of significant risk factors.
    • If symptoms of otitis externa are not responding to management in primary care or are severe, this may indicate progression to necrotizing otitis externa, which requires specialist imaging with CT or MRI to confirm the diagnosis. Treatment may involve prolonged systemic antibiotics and surgical debridement or incision and drainage [Rosenfeld, 2014; Wiegand, 2019; Hopkins, 2020; ENT UK, 2023]. In addition, the person may need specialist tissue sampling and culture to rule out a diagnosis of cholesteatoma or malignancy [Hopkins, 2020].
    • The recommendation if the person is at risk of immunocompromise is based on the fact these people are at higher risk of developing malignant otitis externa [Hopkins, 2020].
    • The recommendation if there is ear canal occlusion is based on the primary care study [Selwyn, 2019], the guidelines [Rosenfeld, 2014; ENT UK, 2023], the guideline on malignant otitis externa [Hopkins, 2020], and expert opinion in review articles [Walton, 2012; Llor, 2014; Wipperman, 2014; Ellis, 2024].
      • If there is extensive swelling of the external ear canal or the tympanic membrane cannot be visualized, aural toilet can remove obstructing debris, and wick insertion may allow topical drug delivery along the length of the ear canal. A systemic antibiotic may be needed if there is severe canal oedema, where aural toilet or wick insertion is not possible or practical [Rosenfeld, 2014; Wipperman, 2014].
      • Microsuction may be needed if ear irrigation and swabbing are ineffective or inappropriate. This allows adequate visualization of the external ear canal to assess for tympanic membrane perforation or signs of other diagnoses such as malignant otitis externa [Hopkins, 2020]. In addition, removal of debris may reduce microbial load and improve delivery of topical drugs to the external ear canal [Llor, 2014].
    • The recommendation if there is cellulitis extending beyond the external ear canal is extrapolated from the primary care study [Selwyn, 2019].
      • The information about the potential need for systemic antibiotics is based on the US clinical practice guideline [Rosenfeld, 2014]. It is also pragmatic, based on what CKS considers to be good clinical practice.
Considering referral to dermatology

Scenario: Chronic otitis externa

From age 3 months onwards.

How should I manage a person with chronic otitis externa?

If a person presents with chronic otitis externa:

  • Provide advice on sources of information and support, such as:
  • Reinforce advice on self-care measures for symptom relief and to reduce risk of recurrent infection.
  • Manage any underlying causes or risk factors including associated skin conditions, where possible.
    • If the person has irritant or allergic contact dermatitis or sensitivity to topical preparations (such as neomycin ear drops), ear plugs, hearing aids, or earrings, advise them to avoid contact with the irritant or allergen where possible. See the CKS topic on Dermatitis - contact for more information on management.
  • Advise on options for analgesia such as paracetamol or ibuprofen for symptom relief, if needed.
  • Consider arranging an ear swab for bacterial and fungal microscopy, culture, and sensitivity, and arrange treatment depending on the result.
    • See the section on Assessment for more information.
  • Consider cleaning the external auditory canal ('aural toilet'), to enable topical treatments to be applied effectively. Options include:
    • Dry swabbing of secretions.
    • Ear irrigation to remove debris, earwax, and exudate, if the tympanic membrane is visualized and intact.
  • Consider prescribing a topical ear preparation, depending on clinical judgement.
    • If there are signs of fungal infection in the ear canal, options include:
      • A topical antifungal preparation, such as clotrimazole 1% solution applied 2–3 times a day, to be continued for at least 14 days after infection has resolved.
      • Clioquinol and a corticosteroid: 2–3 drops twice daily for 7–10 days.
      • Over-the-counter acetic acid 2% ear drops or spray (off-label indication, for people aged 12 years and older) morning, evening, and after swimming, showering, or bathing, for a maximum of 7 days.
    • If there is suspected bacterial infection, manage as for acute otitis externa.
    • If there is no obvious fungal or bacterial infection:
      • Consider prescribing a topical corticosteroid preparation such as prednisolone ear drops 2–3 drops every 2–3 hours until symptoms improve, or betamethasone ear drops 2–3 drops 3–4 times a day. If symptoms improve, continue treatment using the lowest potency and/or frequency of application needed to control symptoms.
      • If symptoms persist despite topical corticosteroid treatment, consider a trial of a topical antifungal preparation instead.
    • See the section on Topical ear preparations in Prescribing information for more information on available preparations, how to administer, and contraindications to use.
  • Arrange follow up to reassess the person, depending on clinical judgement, if:
    • Symptoms persist or are worsening despite treatment in primary care.
    • The person is immunocompromised and at risk of necrotizing otitis externa or other complications.
  • Consider the need to seek specialist advice or arrange specialist referral.

Basis for recommendation

The recommendations on management of chronic otitis externa are based on the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS) clinical practice guideline Acute otitis externa [Rosenfeld, 2014], the ENT UK Global guideline on Otitis Externa [ENT UK, 2023], a UK consensus document Acute otitis externa: consensus definition, diagnostic criteria and core outcome set development [Smith, 2021], a primary care study When to refer: validating the Evidence-based Acute otitis externa Referral Score (EARS). Our experience of 287 cases of otitis externa in primary care [Selwyn, 2019],the RCGP learning document Paediatric Hearing - Otitis Externa (Swimmers Ear) [RCGP, 2026], a guideline on the management of malignant otitis externa [Hopkins, 2020], expert opinion in review articles on otitis externa [Walton, 2012; Wipperman, 2014; Wiegand, 2019; Barry, 2021] and on the use of ear swabs in otitis externa [Llor, 2014], and expert opinion in the British National Formulary (BNF) [BNF, 2026].

Advising on self-care measures
Managing underlying causes or risk factors
Advising on analgesia options
  • The recommendation to offer analgesia is based on the guidelines [Rosenfeld, 2014; ENT UK, 2023], the RCGP learning document Paediatric Hearing - Otitis Externa (Swimmers Ear) [RCGP, 2026] and expert opinion in review articles [Wipperman, 2014; Wiegand, 2019]. 
    • The pain caused by acute otitis externa can be intense and severe, because 'the highly sensitive periosteum of the underlying bone is in close proximity to the ear canal skin, especially in the deeper portion of the canal', and this is usually involved in the inflammatory process [Rosenfeld, 2014; Wiegand, 2019].
Arranging an ear swab
  • The recommendation to consider arranging an ear swab is extrapolated from the guidelines [Rosenfeld, 2014; ENT UK, 2023], a UK consensus document [Smith, 2021], a guideline on malignant otitis externa [Hopkins, 2020], and expert opinion in review articles [Llor, 2014; Wipperman, 2014; Wiegand, 2019; Barry, 2021].
    • Treatment failure may be due to 'microbiological factors', such as fungal infection, resistant bacteria, or unusual causes of infection that need targeted topical or systemic therapy. Fungal infection can cause persistent infection in the ear canal if flora is altered following topical antibiotic therapy [Rosenfeld, 2014; ENT UK, 2023].
    • Uncommon microorganisms, such as anaerobes and fungi, are more often isolated in recurrent disease [Llor, 2014].
Arranging 'aural toilet'
  • The recommendation to consider dry swabbing of secretions is based on guidelines [Rosenfeld, 2014; ENT UK, 2023] and expert opinion in review articles [Wipperman, 2014; Barry, 2021].
    • Aural toilet is important to maximize the efficacy of topical treatment, allowing it to penetrate the ear canal and reach the site of infection [Rosenfeld, 2014; ENT UK, 2023].
  • The recommendation to consider ear irrigation is extrapolated from guidelines [Rosenfeld, 2014; ENT UK, 2023], a guideline on the management of otitis externa [Hopkins, 2020], and expert opinion in review articles [Wipperman, 2014; Wiegand, 2019; Barry, 2021].
    • Ear exudate may contain toxins that sustain the inflammatory process, and debris may also reduce or prevent the effective delivery of topical treatment [Wiegand, 2019].
    • The US clinical practice guideline notes that there is an increased risk of developing malignant otitis externa if ear irrigation is performed in a person who is immunocompromised [Rosenfeld, 2014; Wipperman, 2014; Hopkins, 2020]. In addition, CKS notes that expert opinion in a review article does not recommend ear syringing for people with acute otitis externa, as this may be very painful [Barry, 2021].
Prescribing a topical ear preparation
  • The recommendations on management of suspected fungal infection are based on expert opinion in review articles, which recommend the use of topical clotrimazole or acetic acid [Llor, 2014; Wipperman, 2014]. The information on dosing instructions is based on expert opinion in the BNF [BNF, 2026]. In addition, the manufacturers' Summary of Product Characteristics for acetic acid 2% ear spray notes that this preparation is reported to be active against Candida species [EMC, 2025]. The information that this is an off-label indication for topical acetic acid is based on expert opinion in the BNF [BNF, 2026].
  • The recommendation on management of suspected bacterial infection is based on expert opinion in review articles [Wipperman, 2014; Wiegand, 2019].
  • The recommendations on empirical use of a topical corticosteroid preparation are based on expert opinion in a review article [Wipperman, 2014]. They are also pragmatic, based on what CKS considers to be good clinical practice. The information on dosing instructions is based on expert opinion in the BNF [BNF, 2026].
  • The recommendation to consider a trial of a topical antifungal preparation if symptoms persist is pragmatic, based on what CKS considers to be good clinical practice.
Arranging follow up
  • The recommendations on when to arrange follow up are extrapolated from a primary care study on when to refer [Selwyn, 2019], a guideline on the management of malignant otitis externa [Hopkins, 2020], and expert opinion in a review article [Wiegand, 2019]. They are also pragmatic, based on what CKS considers to be good clinical practice.
    • The recommendation if the person is at risk of immunocompromise is based on the fact these people are at higher risk of developing malignant otitis externa [Hopkins, 2020].
    • Expert opinion in a review article notes that underlying fungal or bacterial infection causing chronic otitis externa can be difficult to treat [Wiegand, 2019].

When should I seek specialist advice or refer for chronic otitis externa?

  • Arrange emergency hospital admission or urgent referral to an ear, nose, and throat (ENT) specialist if:
  • Seek specialist advice or arrange referral to an ENT specialist, the urgency depending on clinical judgement, if:
    • Symptoms persist despite optimal management in primary care. See the section on Initial management for more information.
    • Ongoing topical treatment is needed for symptom control beyond 2–3 months. See the section on Initial management for more information.
    • The person is elderly, has poorly controlled diabetes mellitus or another cause of immunocompromise, depending on clinical judgement.
    • There is ear canal occlusion due to ear discharge, swelling, or debris which is causing difficulty using topical treatment effectively.
      • Specialist microsuction or ear wick insertion may be needed.
    • There is cellulitis extending beyond the external ear canal which cannot be managed in primary care. See the CKS topic on Cellulitis - acute for more information.
      • Systemic antibiotics may be needed, following specialist advice.
  • Consider referral to a dermatology specialist if contact sensitivity to neomycin or another aminoglycoside ear preparation, ear plugs, hearing aids, or earrings is suspected.
    • Patch testing to confirm contact sensitivities may be needed.

Basis for recommendation

The recommendations on referral are largely extrapolated from the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS) clinical practice guideline Acute otitis externa [Rosenfeld, 2014], the ENT UK Global guideline on Otitis externa [ENT UK, 2023], a primary care study When to refer: validating the Evidence-based Acute otitis externa Referral Score (EARS). Our experience of 287 cases of otitis externa in primary care [Selwyn, 2019], the RCGP learning document Paediatric Hearing - Otitis Externa (Swimmers Ear) [RCGP, 2026] a guideline on the management of malignant otitis externa [Hopkins, 2020], and expert opinion in review articles on otitis externa [Walton, 2012; Wipperman, 2014; Wiegand, 2019; Barry, 2021] and on the use of ear swabs in otitis externa [Llor, 2014].

Arranging hospital admission or urgent ENT referral
  • The recommendations on when to arrange emergency hospital admission or urgent referral are extrapolated from the primary care study [Selwyn, 2019] and expert opinion in a review article [Barry, 2021]. They are also pragmatic, based on what CKS considers to be good clinical practice.
    • A multicentre, retrospective analysis of primary care records of 239 patients with otitis externa was used to assess the validity of the 'Evidence-based Acute otitis externa Referral Score (EAR Score)', a risk stratification score designed to help identify patients at higher risk of complications needing specialist referral [Selwyn, 2019].
      • The scoring system assessed clinical domains of risk factors (such as uncontrolled diabetes mellitus or other causes of immunocompromise); duration of treatment (including uncontrolled symptoms during treatment or persistent symptoms at 14 days after treatment started); and red flags (including complications). It had a sensitivity of 100%, specificity of 90%, and negative predictive value of 100%.
Seeking specialist advice or arranging ENT referral
  • The recommendations on when to seek specialist advice or arrange referral are extrapolated from the primary care study on acute otitis externa [Selwyn, 2019], current guidelines [Rosenfeld, 2014; ENT UK, 2023], the RCGP learning document Paediatric Hearing - Otitis Externa (Swimmers Ear) [RCGP, 2026] a guideline on malignant otitis externa [Hopkins, 2020], and expert opinion in review articles [Walton, 2012; Wipperman, 2014; Wiegand, 2019].
    • A multicentre, retrospective analysis of primary care records of 239 patients with otitis externa was used to assess the validity of the 'Evidence-based Acute otitis externa Referral Score (EAR Score)', a risk stratification score designed to help identify patients at higher risk of complications needing specialist referral [Selwyn, 2019].
      • The scoring system assessed clinical domains of risk factors (such as uncontrolled diabetes mellitus or other causes of immunocompromise); duration of treatment (including uncontrolled symptoms during treatment or persistent symptoms at 14 days after treatment started); and red flags (including complications). It had a sensitivity of 100%, specificity of 90%, and negative predictive value of 100%.
      • It recommends ENT referral if there are recurrent episodes of acute otitis externa, persistent symptoms despite adequate treatment, and/or the presence of significant risk factors.
    • If symptoms of otitis externa are not responding to management in primary care or are severe, this may indicate progression to malignant otitis externa, which requires specialist imaging with CT or MRI to confirm the diagnosis. Treatment may involve prolonged systemic antibiotics and surgical debridement or incision and drainage [Rosenfeld, 2014; Wiegand, 2019; Hopkins, 2020]. In addition, the person may need specialist tissue sampling and culture to rule out a diagnosis of cholesteatoma or malignancy [Hopkins, 2020].
    • The recommendation if the person is at risk of immunocompromise is based on the fact these people are at higher risk of developing malignant otitis externa [Hopkins, 2020].
    • The recommendation if there is ear canal occlusion is based on the primary care study [Selwyn, 2019], the US clinical practice guideline [Rosenfeld, 2014], the guideline on malignant otitis externa [Hopkins, 2020], and expert opinion in review articles [Walton, 2012; Llor, 2014; Wipperman, 2014].
      • If there is extensive swelling of the external ear canal or the tympanic membrane cannot be visualized, aural toilet can remove obstructing debris, and wick insertion may allow topical drug delivery along the length of the ear canal. A systemic antibiotic may be needed if there is severe canal oedema, where aural toilet or wick insertion is not possible or practical [Rosenfeld, 2014; Wipperman, 2014].
      • Microsuction may be needed if ear irrigation and swabbing are ineffective or inappropriate. This allows adequate visualization of the external ear canal to assess for tympanic membrane perforation or signs of other diagnoses such as malignant otitis externa [Hopkins, 2020]. In addition, removal of debris may reduce microbial load and improve delivery of topical drugs to the external ear canal [Llor, 2014].
    • The recommendation if there is cellulitis extending beyond the external ear canal is based on the primary care study [Selwyn, 2019].
    • The information about the potential need for systemic antibiotics is based on the US clinical practice guideline [Rosenfeld, 2014]. It is also pragmatic, based on what CKS considers to be good clinical practice.
Considering referral to dermatology
  • The recommendation about dermatology referral and the possible need for patch testing is based on the US clinical practice guideline [Rosenfeld, 2014] and expert opinion in a review article [Wipperman, 2014].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Topical ear preparations

What topical ear preparations are available?

Table 1. Topical ear preparations available in the UK for treating otitis externa.

Group

Products

Astringent/acidic preparations
Astringent/Acidic

Aluminium acetate 8%* and 13% drops; combined acetic acid 8.25% with aluminium acetate and aluminium acetotartrate 1.8% spray (Otinova®)†

Acetic acid 2% spray (Earcalm®)†

Corticosteroid preparations
Corticosteroid: lower potencyPrednisolone sodium phosphate 0.5% drops (Predsol®)
Corticosteroid: higher potencyBetamethasone sodium phosphate 0.1% drops (Betnesol®, Vista-methasone®)
Antibiotic preparations
AminoglycosideGentamicin 0.3% drops (Genticin®)
Fluoroquinolone 

Ciprofloxacin 2mg/ml (Ciloxan®, Cetraxal®)

Antifungal preparations
AntifungalClotrimazole 1% solution (Canesten®)
Combined corticosteroid and antibiotic preparations
Ciprofloxacin

Ciprofloxacin 0.3%, dexamethasone 0.1% ear drops

Fluocinolone 0.25mg/ml, ciprofloxacin 3mg/ml (Cetraxal plus®)

Aminoglycoside with corticosteroid
Neomycin

Betamethasone sodium phosphate 0.1%, neomycin sulphate 0.5% (drops: Betnesol-N®, Vista-Methasone N®)

Hydrocortisone 1%, neomycin sulphate 3400 units, polymyxin B sulphate 10,000 units/mL (drops: Otosporin®)

Prednisolone sodium phosphate 0.5%, neomycin sulphate 0.5% (drops: Predsol-N®)

Dexamethasone 0.1%, neomycin sulphate 3250 units/mL, glacial acetic acid 2% (spray)

GentamicinHydrocortisone acetate 1%, gentamicin 0.3% (drops: Gentisone HC®)
FramycetinDexamethasone 0.05%, framycetin sulphate 0.5%, gramicidin 0.005% (drops: Sofradex®)
Combined corticosteroid and antibiotic/antifungal preparations
Clioquinol with corticosteroidFlumetasone pivalate 0.02%, clioquinol 1% 
*Aluminium acetate 8% can be made by diluting 8 parts aluminium acetate ear drops (13%) with 5 parts purified water (must be freshly prepared before use). †Available to buy over-the-counter. 
Information from: [BNF, 2026]

What advice should I give about administering ear drops?

If possible, ask the person to allow another person to administer a topical ear preparation.

  • Warm the drops to body temperature by holding the bottle in the hands or pocket for a few minutes (to reduce the risk of adverse effects such as dizziness which can occur if cold drops are administered).
  • To administer the ear drops to ensure optimal delivery throughout the external ear canal:
    • The person should lie down with the ear to be treated uppermost.
    • The ear canal should be filled with ear drops. Gently pulling and pushing the ear helps to let air out of, and liquid into, the ear canal.
    • The person should remain in this position for 3–5 minutes.
    • If the person cannot lie still long enough to allow absorption, a small cotton plug covered with petroleum jelly or moistened with the drops and placed at the external opening of the ear canal for about 5 minutes can be used to help retain the drops in the ear.
    • A small cotton swab placed at the tragus can be used to catch any leakage from the ear when sitting up.
    • The ear canal should be left open to dry.

[Rosenfeld, 2014]

What are the contraindications for topical ear preparations?

  • Ototoxicity and contact sensitivity reactions
    • Topical aminoglycoside preparations are contraindicated in people with a perforated tympanic membrane due to the risk of ototoxicity, but may be used on the advice of a specialist.
    • Prescribe a non-ototoxic preparation if the person has a known or suspected perforation of the tympanic membrane, including a tympanostomy tube in situ.
    • If there is a history of suspected contact sensitivity to a topical ear preparation, advise to avoid all preparations with the same class of drug associated with the reaction. For example, if neomycin is thought to have caused a sensitivity reaction, all preparations containing aminoglycosides should be avoided.

[Rosenfeld, 2014; ENT UK, 2023] 

Table 2. Drug compounds or excipients in topical ear preparations reported to cause contact sensitization.

Group

Chemicals

AntibioticsNeomycin, gentamicin sulphate 1%, framycetin, polymyxin B sulphate, chloramphenicol, bacitracin
CorticosteroidsHydrocortisone
ExcipientsBenzethonium chloride (preservative), benzalkonium chloride 0.1% (preservative), caine mix, methyl-methacrylate, methyl-p-oxybenzoate (preservative), methylrosaniline (gentian violet), nickel sulphate 5%, propylene glycol (preservative), quinolone mix 6%, thimerosal merthiolate (preservative)
Data from: [Sood, 2002]

Supporting evidence

This CKS topic is largely based on the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS) clinical practice guideline Acute otitis externa [Rosenfeld, 2014], the ENT Global guideline on Otitis externa [ENT UK, 2023] , a UK consensus document Acute otitis externa: consensus definition, diagnostic criteria and core outcome set development [Smith, 2021], a primary care study When to refer: validating the Evidence-based Acute otitis externa Referral Score (EARS). Our experience of 287 cases of otitis externa in primary care [Selwyn, 2019], the RCGP learning document Paediatric Hearing - Otitis Externa (Swimmers Ear)[RCGP, 2026] ,a guideline on the management of malignant otitis externa [Hopkins, 2020], and expert opinion in review articles. The rationale for recommendations is summarized in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of otitis externa.

Search dates

August 2021 - August 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Otitis externa/, (otitis AND externa$).tw., (swimmer's ADJ ear).tw.
  • Diffuse* malignant* necrotizing* acute* chronic* swimmer*.kw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Agius, A.M., Pickles, J.M. and Burch, K.L. (1992) A prospective study of otitis externa. Clinical Otolaryngology and Allied Sciences 17(2), 150-154. [Abstract]
  • Barry, V., Bhamra, N., Balai, E. and Maung, S. (2021) Otitis externa. BMJ 372. [Abstract]
  • BNF (2026) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk [Free Full-text]
  • Di Traglia, R., Tudor-Green, B., Muzaffar, J., et al. (2023) Antibiotics versus non-antibiotic treatments for acute otitis externa: A systematic review and meta-analysis. Clinical Otolaryngology 48(6), 841-862. [Abstract] [Free Full-text]
  • Ellis, J., De La Lis, A., Rosen, E., et al. (2024) Approach to otitis externa. Canadian Family Physician 70(10), 617-623. [Abstract] [Free Full-text]
  • EMC (2025) SPC for EarCalm spray. Electronic medicines Compendium. Data pharm Communications Limited. https://www.medicines.org.uk [Free Full-text]
  • ENT UK (2023) Otitis externa - Global ENT Guideline Otitis externa - Global ENT Guideline. ENT UK. https://www.entuk.org [Free Full-text]
  • Hopkins, M.E., Bennett, A., Henderson, N., et al. (2020) A retrospective review and multi-specialty, evidence-based guideline for the management of necrotising otitis externa. Journal of Laryngology and Otology 134(6), 487-492. [Abstract]
  • Jackson, E.A. and Geer, K. (2023) Acute Otitis Externa: Rapid Evidence Review. American Family Physician 107(2), 145-151. [Abstract] [Free Full-text]
  • Kirubalingam, K., You, P. and Bajin, D. (2026) Otitis externa. CMAJ 198(25), E977. [Abstract] [Free Full-text]
  • Kong, D., Linton, S. and Stapleton, E. (2025) The incidence and epidemiology of necrotising otitis externa in England before, during and after the coronavirus disease 2019 pandemic: an updated analysis of Hospital Episode Statistics data 2002-2024. Journal of Laryngology and Otology 139(10), 1-7. [Abstract] [Free Full-text]
  • Llor, C., McNulty, C.A. and Butler, C.C. (2014) Ordering and interpreting ear swabs in otitis externa. BMJ 349(Sep 01), g5259. [Abstract]
  • RCGP (2026) Paediatric Hearing - Otitis Externa (Swimmers Ear) Deafness and hearing loss toolkit: Paediatric Hearing - Otitis Externa (Swimmers Ear). Royal College of General Practitioners. https://www.rcgp.org.uk [Free Full-text]
  • Rosenfeld, R.M., Schwartz, S.R. and Cannon, C.R. (2014) Clinical practice guideline: acute otitis externa. Otolaryngology - head and neck surgery 150(1 Suppl), S1-S24. [Abstract] [Free Full-text]
  • Rowlands, S., Devalia, H., Smith, C., et al. (2001) Otitis externa in UK general practice: a survey using the UK General Practice Research Database. British Journal of General Practice 51(468), 533-538. [Abstract]
  • Selwyn, D.M. and Lau. A. (2019) When to refer: validating the Evidence-based Acute otitis external Referral Score (EARS). Our experience of 287 cases of otitis externa in primary care. Clinical Otolaryngology 44(3), 475-479. [Abstract]
  • Smith, M.E., Hardman, J.C., Mehta, N., Jones, G.H. et al. (2021) Acute otitis externa: consensus definition, diagnostic criteria and core outcome set development. PLoS One 16(5). [Abstract]
  • Sood, S., Strachan, D.R., Tsikoudas, A. and Stables, G.I. (2002) Allergic otitis externa. Clinical Otolaryngology and Allied Sciences 27(4), 233-236. [Abstract]
  • Walton, L. (2012) Otitis externa. BMJ 344(May 30), e3623. [Abstract]
  • Wiegand, S., Berner, R., Schneider, A., et al. (2019) Otitis externa. Deutsches Arzteblatt International 116(13), 224-234. [Abstract]
  • Wipperman, J. (2014) Otitis externa. Primary Care 41(1), 1-9. [Abstract]
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