Management considerations

OE is most usually caused by infection but may be caused by allergies, irritants or inflammatory conditions. Approximately 90 per cent of infected OE cases are bacterial. Pseudomonas infections account for two-thirds, and staphylococcal are the next most common. The remaining 10 per cent of infections are fungal, with aspergillus being the most common form. For mild cases, acetic acid drops are often sufficient to help clear the infection, and these can be provided by the pharmacy. For more severe or persistent cases, topical treatments containing an antibiotic alone or in combination with a corticosteroid are usually effective (see Table 2).

Pain should be managed with paracetamol or ibuprofen. Oral antibacterials are rarely indicated. A systemic antibacterial may be considered if the infection is spreading outside the ear canal, the patient is systemically unwell, or in a high-risk group (e.g. people with diabetes, immunocompromised patients, those with severe infection or at high-risk of severe infection such as pseudomonas).

Particularly severe cases, mainly where the ear canal is swollen or occluded, may be treated by clearing the ear out using microsuction, followed by packing the ear with a gauze soaked in antiseptic. This is usually done by ear, nose and throat specialists. These cases can be very painful and there may be systemic features such as lymphadenopathy and pyrexia. Oral or parenteral antibiotics are generally required.

A boil (furuncle) in the ear canal, usually caused by staphylococcal infection, can cause intense pain because of pressure in the confined skin and cartilage. There may be associated cellulitis and if so, systemic antibiotics are indicated. Flucloxacillin would be the treatment of choice in those not allergic to penicillins.

Effective pain relief can be achieved using paracetamol or ibuprofen. These can be combined with codeine when the pain is more severe, although the evidence of benefit is not definitive. Applying heat by holding a hot flannel against the ear can help to relieve pain.