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 – and to never miss necrotising (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 (malignant) | Severe deep pain worse at night, granulation tissue, cranial nerve palsy; diabetic/immunocompromised | Urgent ENT (ear, nose and throat) referral / 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. |
Source: NICE · UKHSA
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