Acute Otitis Externa: Updated Clinical Practice Guidelines

April 2, 2014

Acute Otitis Externa: Updated Clinical Practice Guidelines

  1. Louis M. Bell, MD

Updated guidelines address diagnosis, use of oral and topical antimicrobials, and need for pain relief in patients aged 2 years and older.

  1. Louis M. Bell, MD

Sponsoring Organization: The American Academy of Otolaryngology–Head and Neck Surgery

Target Population: Primary care and specialty clinicians (physicians, nurse practitioners, physician assistants)

What's Changed

The updated guidelines are based on new evidence with an emphasis on patient education, appropriate use of oral and topical antimicrobials, and adequate pain relief.

Background and Objective

Diffuse acute otitis externa (AOE) is diffuse inflammation of the external ear canal (including the pinna or tympanic membrane). Diagnostic factors include rapid onset (within 48 hours) in the past 3 weeks, symptoms of ear canal inflammation (otalgia, itching, or fullness), and signs of ear canal inflammation (tenderness of the tragus, pinna, or both or ear canal edema or redness). Symptoms can include hearing loss or jaw pain. Signs can include otorrhea, regional lymphadenitis, tympanic membrane redness, and cellulitis of pinna and adjacent skin.

Key Action Statements

These updated guidelines target patients aged ≥2 years with AOE, which is almost exclusively bacterial infection. The following recommendations replace the 2006 guidelines and reflect new evidence from 12 randomized, controlled trials and 2 systemic reviews.

Topical Otic Preparations Approved by the FDA for Treating Acute Otitis Externa
Topical Otic Preparations Approved by the FDA for Treating Acute Otitis Externa
  • Differential diagnosis: Using the definition and diagnostic criteria above, distinguish AOE from other causes of otalgia, otorrhea, and cellulitis.

  • Modifying factors: Be aware of factors that modify management. For example, perforated tympanic membranes or tympanostomy tubes require a topical otic preparation that has no potential for ototoxicity. Patients with diabetes or immune deficiency might need systemic antibiotics.

  • Pain management: Recommend analgesic treatment based on pain severity. Treatment with acetaminophen or ibuprofen is an important part of therapy for AOE.

  • Systemic antimicrobials: Systemic antibiotics are not recommended for uncomplicated AOE.

  • Topical therapy: Prescribe topical otic preparations. FDA-approved preparations for treating AOE are shown in the table.

  • Topical drug delivery: Instruct patients on the proper way to administer otic drops. For example, patients should lie down with the effected ear facing up, fill the canal, and remain in position for 3 to 5 minutes. Gentle movement of the ear or pushing on the tragus helps the solution to penetrate. Physicians should place a wick in the canal when it appears swollen.

  • Nonintact tympanic membrane: Prescribe a nontoxic topical preparation (see table) when patients have known or suspect perforation of the tympanic membrane (including tympanostomy tubes). Avoid aminoglycoside- or chloramphenicol-containing otic solutions.

  • Outcome assessment and follow-up: Reassess and exclude other diagnoses in patients who do not respond to treatment within 48 to 72 hours.


The executive summary includes helpful patient information and instructions for use of topical treatment.

Editor Disclosures at Time of Publication

  • Disclosures for Louis M. Bell, MD at time of publication Grant / research support Institutional Clinical and Translational Science Award; National Center for Pediatric Practice Based Research Learning Editorial boards Current Problems in Pediatric Adolescent Healthcare Leadership positions in professional societies Academic Pediatric Association (Chair, Academic General Pediatrics Fellowship Accreditation Committee)


Reader Comments (1)

Siamsasi Resident, Otolaryngology, Surakarta, indonesia

Very good article

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