NPC Archive Item: New CKS (PRODIGY) guidance on otitis externa

NOTE – This is an archive post from the NPC and has not been updated since first publication. Therefore, some hyperlinks may no longer be working.

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What is this about?
While otitis externa is commonly seen in UK general practice, it is often difficult to find evidence to guide our practice in this area. Clinical Knowledge Summaries (CKS, formerly called PRODIGY) have issued updated guidance on this area.

What is the background here?
In the UK, more than 1% of people each year are diagnosed with otitis externa (inflammation of the external ear canal), which may be acute (less than three weeks), or chronic (more than three months). Causes include irritant, allergic or seborrhoeic dermatitis, a bacterial or fungal infection, rarely a malignancy, and, in some cases, there may be no identified cause. There is no directly relevant evidence from clinical trials to guide practice in the management or treatment of otitis externa, so recommendations are largely based on expert opinion and other guidelines.

What does the guidance say?
This CKS topic review is the prime source of summarised evidence for otitis externa in the UK. It provides pragmatic advice on prevention and treatment of otitis externa, what methods to use for cleaning the auditory canal, which patients to follow up, and when to refer or seek specialist advice.

The guidance includes the following advice on the treatment of acute diffuse otitis externa:

  • Investigations are rarely useful. Consider an ear swab for bacterial/fungal culture if treatment fails, or if otitis externa recurs frequently.
  • Identify and remove any precipitating or aggravating factors. Treat any underlying skin condition such as eczema and psoriasis.
  • Paracetamol or ibuprofen is usually sufficient for pain relief. Codeine can be added if the pain is severe.
  • Prescribe topical ear preparations for seven days, e.g. flumetasone-clioquinol ear drops. Although aminoglycoside ear drops may be used as an alternative, with or without a corticosteroid, their use is contraindicated if the tympanic membrane is perforated. Consider oral antibiotics for severe infection.
  • Assess factors that would impede delivery of topical medication to affected areas. Consider cleaning the external auditory canal, if there is sufficient earwax or debris to obstruct topical medication, and/or inserting an ear wick, if there is extensive swelling of the auditory canal (both may require referral).
  • Give patients advice on self-care.
  • Most cases resolve within a few days of starting treatment and do not need follow up. However, consider follow-up in people with diabetes, with compromised immunity, or with accompanying cellulitis that has spread outside of the auditory canal.

The CKS guidance should be consulted for further details and advice on localised and chronic diffuse otitis externa.