Intended for healthcare professionals

Practice 10-Minute Consultation

Otitis externa

BMJ 2021; 372 doi: (Published 31 March 2021) Cite this as: BMJ 2021;372:n714
  1. Veronica Barry, ear, nose, and throat speciality doctor1,
  2. Navdeep Bhamra, core surgical trainee 11,
  3. Edward Balai, speciality trainee 2 in ear, nose, and throat1,
  4. Steven Maung, general practitioner2
  1. 1Royal Wolverhampton Trust, Wolverhampton, UK
  2. 2Bilbrook Medical Centre, Wolverhampton, UK
  1. Correspondence to V E Barry veronica.barry{at}

What you need to know

  • Acute uncomplicated otitis externa can be managed effectively with topical treatments, for up to 14 days if required

  • Clues for malignant otitis externa include fever, disproportionate pain, or a poor response to first line treatment, particularly in people with diabetes or immunocompromise

  • Consider cholesteatoma in patients with recurrent discharge

A 57 year old man presents to his general practitioner with a 3 day history of severe right sided ear pain, reduced hearing, and discharge. He is a self-employed car mechanic with a small business, and has been absent from work for the past two days because of the pain and subsequent lack of sleep. He has hypertension and type 2 diabetes.

Otitis externa is an infection of the skin of the outer ear canal which typically presents with severe otalgia with or without ear discharge and reduced hearing. It is a common condition with an annual incidence of 1% that affects 10% of the population during their lifetime.12 In 98% of cases the cause is bacterial, with Pseudomonas aeruginosa and Staphylococcus aureus the most common pathogens.3 Otitis externa often causes severe pain and can have a major impact on quality of life, disturbing sleep, and the ability to work or exercise.

What you should cover

As with any primary care consultation, take a focused history to narrow down the differential diagnosis (table 1) and explore the patient’s ideas and concerns. Ask specifically about risk factors and clinical features for malignant otitis externa (box 1). This extension of the infection into the temporal bone can be easily missed and is a serious complication requiring long term intravenous antibiotic treatment. If not treated it may lead to sepsis and intracranial complications.

View this table:
Table 1

Differential diagnosis3

Box 1

Malignant otitis externa

Malignant otitis externa is a rare but serious extension of otitis externa, whereby infection spreads to surrounding structures leading …

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