• Presence of white, cotton-like strands of candida, or small, black or white dots of aspergillus is suggestive of fungal colonisation: clotrimazole 1% solution.

Management

• Topical acetic acid 2% spray (available OTC as EarCalm®, neomycin sulphate, + corticosteroid) OR neomycin sulphate with corticosteroid ear drops.

• If cellulitis: flucloxacillin (oral). symptoms >2 weeks, in particular DM, refer to exclude malignant OE caused by Pseudomonas aeruginosa & not responding to fluclox

Necrotising or malignant OE

• OE which has spread to cause osteomyelitis of the skull base. Due to Pseudomonas aeruginosa and anaerobes causing a mound of tissue in the external canal. A facial nerve palsy occurs in 50% of patients with this condition, and nerves IX to XII may also be involved. It affects immunocompromised patients, especially elderly diabetics. It may be life threatening and is worth considering in diabetic patients presenting with ear pain.

Resources

• Otitis externa (CKS), Management of patients presenting with otorrhoea: diagnostic and treatment factors (BJGP)