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Otitis Externa & Otitis Media

A practical on-call guide to managing ear infections — from simple otitis externa to the life-threatening malignant variant, and from acute otitis media to its complications.

Clinical Reminder: This material is for educational use by qualified medical professionals. Always consult a senior if you are unsure about any procedure. Never perform a procedure you are not competent to carry out.

Otitis Externa

Otitis externa is an infection of the skin lining the external auditory canal. It is one of the most common ENT presentations both in general practice and on-call. The canal skin becomes inflamed, oedematous, and often debris-laden, leading to a characteristic constellation of symptoms and signs.

Causes

The condition is usually bacterial, with Pseudomonas aeruginosa and Staphylococcus aureus being the predominant organisms. Fungal otitis externa (otomycosis), caused most commonly by Aspergillus or Candida species, accounts for around 10% of cases and typically presents with intense itching, a white or black powdery debris, and a less painful canal. Predisposing factors include:

  • Swimming — prolonged water exposure disrupts the protective acidic environment of the canal (often called "swimmer's ear")
  • Trauma — cotton bud use, hearing aid use, or over-zealous ear cleaning removes the protective cerumen layer
  • Eczema and psoriasis — pre-existing skin conditions predispose to canal infection
  • Diabetes mellitus and immunosuppression — increase susceptibility and risk of severe or necrotising disease

Symptoms

  • Otalgia — often severe and out of proportion to visible signs; worsened by jaw movement
  • Pruritus (itching) of the canal
  • Discharge (otorrhoea) — purulent in bacterial infection; white or black debris in fungal infection
  • Conductive hearing loss — caused by oedema and debris occluding the canal lumen; the tympanic membrane (TM) itself is normal in uncomplicated otitis externa
  • Tragal and/or auricular tenderness on palpation — a key clinical sign helping to distinguish otitis externa from otitis media

Examination Findings

On otoscopy, you will typically find an erythematous, oedematous canal with debris and discharge. The canal may be so narrowed that the TM cannot be visualised. In true otitis externa without complications, the TM — if visible — is normal. Tenderness on pulling the pinna or pressing the tragus is characteristic and helps differentiate otitis externa from otitis media, in which the canal is usually normal but the TM appears abnormal.

Management

  • Microbiological swab — take a swab in all cases before starting treatment, particularly if the infection does not respond to first-line therapy or if fungal infection is suspected.
  • Aural toilet (microsuction) — remove as much debris as possible. Microsuction is the gold standard and, when performed by a trained clinician, is both therapeutic and diagnostic. It allows topical drops to reach the deeper, medial portion of the canal. Do not attempt microsuction if you are not trained to do so; refer to a senior colleague or the emergency ENT clinic.
  • Topical antibiotic and steroid drops — the first-line treatment for bacterial otitis externa. Sofradex (framycetin, gramicidin, dexamethasone) or Gentisone HC (gentamicin, hydrocortisone) 3 drops three times a day is a common regimen. Instruct the patient to lie on their side with the affected ear uppermost, instil one drop and then vigorously shake the pinna or tragus for one minute (if pain allows) to promote distribution of the drop to the medial canal. Repeat with the remaining drops, then remain lying for 10 minutes. This technique significantly improves drug delivery to the deep canal.
  • Ear wick (Pope wick) — if there is significant canal narrowing preventing drops from reaching the medial canal, insert a Pope wick (a compressed cellulose sponge) gently into the deep canal under direct vision. The wick expands on contact with moisture and acts as a vehicle for topical drops, allowing the medication to seep through to the occluded portions of the canal. Instruct the patient to continue applying drops over the wick. The wick should be removed or replaced at follow-up within 24–48 hours.
  • Analgesia — otitis externa can be extremely painful. Simple analgesia (paracetamol, ibuprofen) should be prescribed. NSAIDs are often particularly effective given the inflammatory nature of the condition.
  • Avoid water — advise the patient to keep the ear dry. Cotton wool smeared with petroleum jelly (Vaseline) can be used as a plug when bathing or showering. Swimming should be avoided until fully resolved.
  • ENT emergency clinic — all patients should be referred to the next available emergency ENT clinic (within 2 days) for repeat microsuction and clinical review.

Fungal Otitis Externa (Otomycosis)

If the swab confirms a fungal infection, topical antifungal treatment is required. Clotrimazole 1% solution is the most commonly used agent. The canal should be thoroughly cleaned of fungal debris before antifungal drops are applied, as the fungi tend to form a biofilm that protects them from topical agents. Antifungal treatment typically needs to be continued for 2–4 weeks after the canal appears clear, as recurrence is common.

Malignant (Necrotising) Otitis Externa — Do Not Miss

Malignant or necrotising otitis externa is a severe, potentially life-threatening osteomyelitis of the skull base that begins as an otitis externa. It is almost exclusively seen in diabetic patients and the immunocompromised (e.g., those on chemotherapy, with HIV, or on long-term immunosuppressive therapy). The causative organism is nearly always Pseudomonas aeruginosa.

Key clinical features that should raise suspicion:

  • Severe, unrelenting otalgia disproportionate to clinical findings
  • Granulation tissue on the floor of the external auditory canal at the bony–cartilaginous junction — this is the pathognomonic sign
  • Failure to respond to standard topical therapy
  • Cranial nerve palsies (facial nerve palsy in particular — indicating skull base involvement)
  • Systemic features: fever, raised inflammatory markers (CRP, ESR, WBC)

Management:

  • Urgent ENT referral — do not manage this as a simple otitis externa
  • CT scan of the temporal bones and skull base — to assess extent of bony involvement
  • MRI — better for assessing soft tissue involvement and intracranial extension
  • Nuclear medicine bone scan (Technetium-99) — useful for initial diagnosis and monitoring treatment response
  • IV antipseudomonal antibiotics — ciprofloxacin is the drug of choice (oral bioavailability is high, so oral ciprofloxacin is often used for prolonged courses once the patient is stable); treatment typically lasts 6–8 weeks
  • Strict glycaemic control in diabetic patients
  • Serial inflammatory markers to monitor treatment response

Otitis Media

Otitis media refers to inflammation of the middle ear. There are two main forms that ENT juniors will encounter: acute otitis media (AOM) and otitis media with effusion (OME, or "glue ear"). These have very different clinical presentations and management.

Acute Otitis Media (AOM)

AOM is predominantly a disease of childhood, though it can occur at any age. It typically follows an upper respiratory tract infection, which causes Eustachian tube dysfunction and allows nasopharyngeal bacteria to ascend into the middle ear. The most common causative organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Viral AOM also occurs.

Symptoms

  • Rapid onset of severe otalgia
  • Fever
  • Conductive hearing loss in the affected ear
  • In young children: irritability, pulling at the ear, poor feeding

Examination Findings

The external canal is normal. On otoscopy, the tympanic membrane appears bright red, congested, and often bulging (due to middle ear pus/effusion). Loss of the normal light reflex and bony landmarks is common. Tragal tenderness is absent (distinguishing this from otitis externa). Perforation may occur if the pressure builds sufficiently — at which point the pain typically resolves dramatically, and a purulent discharge appears in the canal.

Management

The NICE guideline (NG91) recommends a stratified approach:

  • Analgesia — this is the single most important immediate treatment. Paracetamol and/or ibuprofen should be prescribed at adequate doses.
  • Watchful waiting — most cases of AOM in children over 2 years will resolve spontaneously within 3–4 days without antibiotics. A "no antibiotic" or "delayed antibiotic prescription" (to be filled only if not improving after 72 hours) strategy is appropriate for mild-to-moderate disease.
  • Immediate antibiotics — indicated if the patient is systemically unwell, if there is no improvement after 72 hours of watchful waiting, if the patient is under 2 years with bilateral AOM, or if there is otorrhoea (perforation). First-line: amoxicillin. If allergic to penicillin: clarithromycin. If severe or not responding: co-amoxiclav (Augmentin).
  • No routine ENT follow-up is required for uncomplicated AOM — this is primarily a GP-managed condition.

Perforated Tympanic Membrane

If AOM progresses to perforation, the pain typically resolves suddenly as the pressure is released, and a purulent discharge appears. Take a microbiological swab. Topical antibiotic drops (e.g., Sofradex) with analgesia are appropriate. Note: some antibiotic ear drops are contraindicated if the TM is perforated due to ototoxicity risk (aminoglycoside drops should be avoided in confirmed perforation). Ciprofloxacin drops are safe with a perforated TM. Ask the GP to review once the infection has resolved to confirm healing of the perforation. If the perforation has not healed within 6 weeks of resolution, an outpatient ENT appointment should be arranged for assessment and possible myringoplasty (surgical repair of the TM).

Otitis Media with Effusion (OME / "Glue Ear")

OME is the accumulation of fluid in the middle ear without signs of acute infection. It is the most common cause of hearing loss in children. On otoscopy, the TM appears dull, retracted, or amber-coloured (from the viscous fluid behind it), and the light reflex is diminished or absent. Air bubbles or a fluid level may occasionally be seen. There is no pain and no fever. Management is primarily with watchful waiting (the majority resolve spontaneously within 3 months). Persistent cases affecting hearing and causing speech/language delay are referred to ENT for consideration of ventilation tube (grommet) insertion.

Complications of Otitis Media

While most cases of AOM resolve without incident, awareness of complications is essential. These include:

  • Mastoiditis — the most common intratemporal complication. The infection spreads to the mastoid air cells posterior to the ear. Classic presentation: post-auricular swelling, erythema and tenderness, with the auricle pushed forward and downward. This is an ENT emergency requiring IV antibiotics, CT scan, and often surgical drainage (cortical mastoidectomy). Refer urgently.
  • Meningitis — haematogenous spread or direct extension through the tegmen tympani. Any child with AOM who develops headache, neck stiffness, or photophobia requires immediate assessment.
  • Labyrinthitis — spread of infection to the inner ear causing sensorineural hearing loss and vertigo.
  • Facial nerve palsy — rare; caused by the nerve being exposed within its bony canal as a result of infection.
  • Brain abscess or sigmoid sinus thrombosis — rare but life-threatening intracranial complications.

Frequently Asked Questions

What is malignant otitis externa and who is at risk?

Malignant (necrotising) otitis externa is an invasive osteomyelitis of the skull base caused almost exclusively by Pseudomonas aeruginosa. It begins in the external ear canal and spreads to the underlying bone. It is almost always seen in diabetic or immunocompromised patients. The hallmark sign is granulation tissue on the floor of the canal at the bony–cartilaginous junction. It can cause facial nerve palsy and other cranial nerve palsies as it erodes the skull base. It requires urgent ENT referral, CT/MRI imaging, and prolonged antipseudomonal antibiotic therapy (typically oral ciprofloxacin for 6–8 weeks). Mortality without treatment is high.

How do I distinguish otitis externa from otitis media clinically?

The key distinguishing features are: (1) Tragal tenderness — present in otitis externa (inflamed canal skin), absent in otitis media. (2) Canal appearance — erythematous, oedematous, and debris-filled in otitis externa; normal in otitis media. (3) Tympanic membrane — normal in otitis externa (if visible); bright red, bulging, or perforated in AOM. (4) Context — otitis externa is more common in adults, often associated with water exposure or trauma; AOM is more common in children and follows URTI.

What is a Pope wick and how does it help in otitis externa?

A Pope wick (ear wick) is a small compressed cellulose sponge that is inserted into a swollen, narrowed ear canal. When the wick comes into contact with moisture it expands, and when the patient applies ear drops onto the wick, the drops are absorbed and slowly released into the deeper portions of the canal — areas otherwise inaccessible because of oedematous narrowing. The wick should be replaced or removed at follow-up (24–48 hours). It is a simple but effective way to ensure topical treatment reaches the medial canal in severe otitis externa.

Are antibiotics always needed for acute otitis media?

No. NICE guidance (NG91) recommends that most children over 2 years with mild-to-moderate AOM can be managed with analgesia alone or with a delayed ("back-pocket") antibiotic prescription to be used only if symptoms have not improved after 72 hours. Spontaneous resolution occurs in the majority without antibiotics. Immediate antibiotics are indicated for: children under 2 years with bilateral AOM, any child with AOM and otorrhoea (perforated TM), severely unwell patients, or those not improving at 72 hours. This approach minimises antibiotic resistance and unnecessary side-effects.

Which ear drops are safe to use if the tympanic membrane is perforated?

Aminoglycoside-containing drops (such as Sofradex, which contains framycetin, or Gentisone HC, which contains gentamicin) are potentially ototoxic and should be avoided with a confirmed or suspected perforation. Ciprofloxacin drops (e.g., Cetraxal) are safe to use with a perforated TM and are a good first-line choice in this scenario. Always check the data sheet and discuss with a senior if uncertain.

ST3 interview: How would you manage a diabetic patient with severe otitis externa who is not improving on topical drops?

This presentation should immediately raise concern for malignant (necrotising) otitis externa. I would take a full history including duration of symptoms, any systemic features (fever, weight loss), and check their current glycaemic control. On examination I would look specifically for granulation tissue on the canal floor at the bony–cartilaginous junction and any cranial nerve deficits. I would request urgent ENT review, CT of the temporal bones and skull base, and baseline bloods including CRP, ESR, and FBC. Treatment involves prolonged antipseudomonal antibiotics (oral ciprofloxacin for 6–8 weeks is first-line), aural toilet, and crucially, optimisation of blood sugar control. Serial CRP and ESR are used to monitor treatment response. If there is intracranial extension, neurosurgical input may be needed.

What are the signs of mastoiditis and why is it an emergency?

Mastoiditis presents with post-auricular swelling, erythema, tenderness, and — classically — the auricle is displaced forwards and downwards as pus collects in the mastoid. There may be a history of preceding or ongoing AOM. It is an emergency because the infection can spread intracranially, causing meningitis, extradural abscess, sigmoid sinus thrombosis, or brain abscess. Management includes urgent ENT referral, IV antibiotics (co-amoxiclav or ceftriaxone), CT scanning to assess extent, and surgical drainage (cortical mastoidectomy) if there is a subperiosteal abscess or the patient fails to respond to medical treatment.

What is the difference between otitis media with effusion (OME) and acute otitis media?

AOM is an acute infection of the middle ear with rapid onset of pain, fever, and a bulging, red TM. OME ("glue ear") is the accumulation of non-infected mucoid fluid in the middle ear — there is no pain, no fever, and no systemic upset. The TM appears dull, retracted, and amber-coloured. OME causes conductive hearing loss, which in children may impact speech and language development. Watchful waiting for 3 months is the first-line approach for OME; persistent cases are referred for grommet insertion.

How should I instil ear drops to maximise effectiveness in otitis externa?

The patient should lie on their side with the affected ear uppermost. One drop is instilled, and the pinna is then vigorously shaken (or the tragus pumped inwards and outwards) for approximately one minute to work the drop into the canal by air-pumping. This sequence is repeated for each drop. The patient should then remain lying with the ear up for a further 10 minutes. This technique significantly improves penetration of the drops to the deep medial canal compared with simply instilling the drops and sitting upright.

When should a non-healing tympanic membrane perforation be referred to ENT?

Most traumatic or post-infective perforations of the tympanic membrane heal spontaneously within 6–8 weeks once the underlying infection has resolved. If the perforation has not healed after 6 weeks, the patient should be referred to ENT outpatients. The options are surveillance (to see if it closes with further time), hearing aid fitting if there is significant conductive hearing loss, or surgical repair (myringoplasty) — typically performed if the perforation is causing recurrent infections, persistent hearing loss, or is affecting quality of life.

References

  1. National Institute for Health and Care Excellence. Otitis media (acute): antimicrobial prescribing. NICE guideline NG91. London: NICE; 2018.
  2. National Institute for Health and Care Excellence. Otitis media with effusion in under 12s: surgery. NICE guideline CG60. London: NICE; 2008 (updated 2023).
  3. Watkinson JC, Clarke RW, eds. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery. 8th ed. Boca Raton: CRC Press; 2018.
  4. Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014;150(1 Suppl):S1–S24.
  5. Carfrae MJ, Kesser BW. Malignant otitis externa. Otolaryngol Clin North Am. 2008;41(3):537–549.
  6. Hobson CE, Moy JD, Byers KE, et al. Malignant otitis externa: evolving pathogens and implications for diagnosis and treatment. Otolaryngol Head Neck Surg. 2014;151(1):112–116.
  7. ENT UK. Clinical guidance on the management of otitis externa. London: ENT UK; 2019.