GPAtlas🧭 When to suspect
Otitis externa (OE) is inflammation of the external ear canal, with or without infection.
• It usually presents with ear pain, itch, and discharge, classically after water exposure ("swimmer's ear") or local trauma from cotton buds.
• The commonest pathogens are Pseudomonas aeruginosa and Staphylococcus aureus.
• Fungal infection (otomycosis) is more typical of chronic or treatment-resistant disease.
Diagnosis is clinical: tragal tenderness or pain on pulling the pinna, with a diffusely oedematous, erythematous canal on otoscopy, supports it.
The two priorities in primary care are:
• To treat topically – oral antibiotics are rarely needed.
• To never miss necrotising otitis externa (previously called malignant otitis externa), a skull-base infection of the elderly, diabetic, or immunocompromised.
| Pattern | Typical features | First action |
|---|---|---|
| Acute localised (furunculosis) | • Folliculitis or a boil in the outer canal • Focal pain and swelling |
• Analgesia • Topical ± oral antibiotic if pointing or spreading |
| Acute diffuse ("swimmer's ear") | • Diffuse canal oedema and erythema, otalgia, discharge • < 3 months |
Topical antibiotic ± corticosteroid (acetic acid if mild) |
| Chronic (> 3 months) | • Itch, dry scaly skin, canal narrowing • Often fungal, eczematous, or contact sensitivity |
• Treat the cause • Consider swab and a topical antifungal/steroid |
| Necrotising | • Severe deep pain worse at night, granulation tissue, cranial nerve palsy • Diabetic/immunocompromised |
Urgent ENT (ear, nose and throat) referral or admission |
|
🧠 Clinical pearl • In necrotising otitis externa the pain is disproportionate to the otoscopic findings. • A relatively unremarkable-looking canal does not reassure. • Deep, boring otalgia that wakes the patient at night in an older person with diabetes is the red flag that should prompt urgent referral, well before granulation tissue or a nerve palsy appears. |
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