Acute Otitis Externa - Primary Care

Publication: 30/09/2010  
Next review: 30/09/2014  
Clinical Guideline
ID: 2227 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2010  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Acute Otitis Externa



1st Line

2nd line

Acute Otitis Externa

Optimise Analgesia (NSAID and Paracetamol)

Ensure ear canal clean and patent

Cure rates similar for topical antibiotic +/- steroid and acetic acid 2% for 7 days treatment 23A+

Refer to a specialist if:

  • disease extends outside of the ear canal (requires directed systemic antibiotics) 24,A+
  • cellulitis/necrotising otitis/canal occlusion
  • systemic signs/symptoms of infection


Acetic Acid 2%
Spray TDS
7 days 23A+ 

Locorten-Vioform (Clioqinol-Flumetasone); 25,A-
2-3 drops BD
7 days 23,A+
Gentisone HC (Hydrocortisone acetate 1% + Gentamicin 0.3% ear drops)
2 drops TDS day and night
7 days Max. §
Otomize (Dexamethasone 0.1%+ Neomycin electronic Medicines Compendium information on Neomycin 0.5%+acetic acid 2% ear spray)
1 spray TDS
7 day Max. §
§ Use alternative if tympanic membrane is perforated

Principles of Treatment

  1. This guidance is based on the best available evidence but its application must be modified by professional judgement.
  2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  3. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  4. Only send microbiology specimens if there is a clinical suspicion of infection. Inappropriate specimens (e.g. routine ulcer swab or routine catheter specimen of urine) lead to inappropriate antibiotic prescribing.
  5. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
  6. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections 1,A+
  7. Limit prescribing over the telephone to exceptional cases.
  8. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTI's.
  9. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
  10. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, and high dose metronidazole. Short-term use of trimethoprim (unless low folate status or taking another folate antagonist such as antiepileptic or proguanil) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus.
  11. We recommend clarithromycin as it has less side-effects than erythromycin, greater compliance as twice rather than four times daily & generic tablets are similar cost. In children erythromycin may be preferable as clarithromycin syrup is twice the cost.
  12. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)


Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = informal opinion


Record: 2227
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:

Acute Otitis Externa

Target patient group:
Target professional group(s): Primary Care Doctors
Adapted from:

This guidance was initially developed in 1999 by practitioners in South Devon, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following comments from Internet users. The guidance has been updated annually as significant research papers, systematic reviews and guidance have been published. The Health Protection Agency works closely with the authors of the Clinical Knowledge Summaries.

Evidence base

Grading of guidance recommendations

The strength of each recommendation is qualified by a letter in parenthesis.

Study design


Good recent systematic review of studies


One or more rigorous studies, not combined


One or more prospective studies


One or more retrospective studies


Formal combination of expert opinion


Informal opinion, other information


Clinical Knowledge Summaries web BNF (No 55), SMAC report - The path of least resistance (1998), SDHCT Medical Directorate guidelines + GU medicine guidelines, Plymouth Management of Infection Guidelines project LRTI and URTI.

Acute Otitis Externa

  1. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database of Systematic Reviews 2010, Issue1. Art. No.:CD004740. DOI: 10.1002/14651858.CD004740.pub2. RATIONALE: The best evidence we have to date. Includes 19 low quality RCT’s only two of which are from primary care. One big downside for primary care is that over half of the trials involved ear cleaning. The meta-analysis demonstrates topical treatments alone are adequate for treating most cases of AOE. Acetic acid was as effective and comparable to antibiotic/steroid for the first 7 days, but inferior after this point. It is important to instruct patients to use drops for at least one week, and to continue for up to 14 days if symptoms persist.
  2. Rosenfeld RM, Brown L, Cannon R, Dolor RJ, Ganiats TG, Hannley M, Kokemueller P, Marcy M, Roland PS, Shiffman RN, Stinnett SS, Witsell DL, Singer M, Wasserman JM. Clinical Practice Guideline: Acute Otitis Externa. Otolaryngology – Head and Neck Surgery 2006;134(4 Suppl)S4-S23 RATIONALE: Up to 40% of patients with AOE receive oral antibiotics unnecessarily. The antibiotics selected are often inactive against P aeruginosa and S aureus. When using topical antibiotics in this situation bacterial resistance is far less of a concern as the high concentration of the drug in the ear canal will generally eradicate all susceptible organisms, plus those with marginal resistance.
  3. Abelardo E, Pope L, Rajkumar K, Greenwood R, Nunez DA. A double-blind randomised clinical trial of the treatment of otitis externa using topical steroid alone versus topical steroid-antibiotic therapy. European archives of oto-rhino-laryngology: 2009;266(1):41-5 RATIONALE: A hospital outpatient RCT showing superiority of topical steroid-antibiotic therapy. The Cochrane Review 2010 also stated that ‘the evidence for steroid-only drops is very limited and as yet not robust enough to allow us to reach a conclusion or provide recommendations.’

Document history

LHP version 1.0

Related information

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