InnovAiT, 0(0), 1–7

Otitis externa
Dr Emma Dickson
GP with a special interest in ENT, Northern Ireland
Email: [email protected]
Twitter handle: @RippleLife

O titis externa is inflammation of the external auditory meatus. It is a common, acute and
chronic presentation to general practice, with around 10% of the population suffering
at least one episode. Pain and itching are common symptoms and affect quality of life.
Identifying the cause of otitis externa can be a challenge. This article considers different
presentations of otitis externa, their diagnosis and management in primary care.

The GP curriculum and otitis externa

Clinical example 3.15: Care of people with ENT, oral and facial problems requires GPs to:
. Demonstrate empathy and compassion towards patients with ENT symptoms that may prove difficult to manage, e.g. tin-
nitus, facial pain, unsteadiness
. Manage primary contact with patients who have common/important ENT, oral or facial problem, e.g. vertigo or tinnitus
. Understand the relationship between factors in the patient’s environment, such as smoking or noise levels, and the cause
and management of their condition
. Understand when urgent (or semi-urgent) referral to secondary care may be indicated, e.g. in trauma, epistaxis, quinsy
(peritonsillar abscess), severe croup or stridor
. Demonstrate knowledge of the scientific backgrounds of symptoms, diagnosis and treatment of ENT, oral and facial
conditions
. Demonstrate an evidence-based approach to antibiotic prescribing
. Understand and implement the key national guidelines that influence healthcare provision for ENT problems
. Understand the significant quality-of-life impairment that may arise from common ENT and oral complaints, e.g. snoring,
rhino sinusitis, persistent oral ulceration and dry mouth

Introduction # Chronic otitis externa, where symptoms last more than 3

months
Otitis externa is more common in women under the age of 65 years
. Malignant otitis externa
and is more prevalent at the end of summer; the peak incidence
occurs in children 7–12 years in age (Rowlands, Devalia, Smith, In localised otitis externa, the root of a hair follicle becomes
Hubbard, & Dean, 2001). Otitis externa means inflammation of the infected, most commonly by Staphylococcus aureus. Infection of the
external auditory meatus. The external auditory meatus is comprised root can progress to form a painful boil or furuncle, which may burst
of an epithelial layer, which contains ceruminous glands, sebaceous spontaneously and subsequently heal.
glands and hair follicles, over deeper skin layers containing sweat In diffuse otitis externa (acute and chronic) disturbance of the
glands. These act to keep the stratum water tight and acidic at a PH PH balance is believed to trigger inflammation of the skin and sub-
between 3 and 5. dermis of the external ear canal. This can extend to the external ear
Otitis externa can present as: and the tympanic membrane. Table 1 lists some of the common
. Localised otitis externa causes.
. Diffuse otitis externa: Known as ‘swimmers ear’ or ‘tropical ear’ As a result of the disruption in PH, secondary infection may occur
# Acute otitis externa, where symptoms last less than 3 weeks and spread to the external ear and tympanic membrane. Common

1 InnovAiT, 2018, Vol. 0(0), 1–7, ! The Author(s) 2018.

Reprints and permissions: sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1755738018763227
journals.sagepub.com/home/ino
 InnovAiT

Table 1. Risk factors.

Risk factor Patients affected
Environmental High humidity/perspiration/swimmers/surfers/daily hair washers

Underlying medical issues Elderly/diabetics/human immunodeficiency virus/immunosuppressed/narrow ear

canals- hereditary or acquired/Previous ear surgery, e.g. tympanostomy

Underlying dermatological Contact dermatitis, e.g. hearing aids, ear plugs, sensitivity to topical preparations/
pathology psoriasis/ eczema/seborrhoeic dermatitis

Exposure to trauma Dirty fingernails/use of cotton buds, hair grips/foreign body/hearing aids/ear plugs/
previous radiotherapy to the head and neck

infective organisms include S. aureus and Pseudomonas aeruginosa. Once the severity is established the underlying causes can be con-
Possible organisms include: sidered. As shown in Table 1, these may include environmental fac-
. Bacterial: S. aureus/P. aeruginosa/Streptococcus pyogenes tors, underlying medical problems, skin disorders and exposure to
. Fungal: local trauma (Rosenfeld et al., 2014).
# Superficial infection: Aspergillus fumigatus, Candida albicans Localised otitis externa typically presents with severe ear pain.
# Deep infections: Epidermophyton, Trichophyton Microsporum When the furuncle bursts there is resolution of the pain.
genera In acute otitis externa, patients will complain of a rapid onset of
symptoms, generally within 48 hours, that last 3 weeks or less. Otalgia is
. Viral: Herpes simplex, herpes zoster
a common presenting symptom, and is exacerbated by jaw movement,
Acute diffuse otitis externa is commonly caused by bacterial and/ otoscope insertion or with movement of the tragus. Patients may also
or fungal infections, seborrhoeic dermatitis, contact dermatitis, trauma experience localised pruritus or otorrhoea. Hearing loss can occur if
or environmental factors. Acute otitis externa is caused by bacterial there is sufficient swelling to occlude the ear canal. Identifying causa-
infection in 98% of all cases (Rosenfield et al., 2014). tive factors is important to avoid progression to chronic otitis externa.
Chronic otitis externa is usually caused by contact dermatitis or In chronic otitis externa, symptoms typically last more than
seborrhoeic dermatitis. However, prolonged use of topical steroids 3 months. Symptoms include persistent localised pruritus and mild
or antibacterial drops can increase susceptibility to secondary fungal discomfort. The itch can affect day-to-day functioning and quality of
infection. It is important to note that bacterial infections do not nor- life. A thorough history is important to identify underlying causes. If a
mally cause chronic otitis externa, but can result from inadequately local cause cannot be found, look for a source of infection, including
treated acute otitis externa. sites of fungal infection, elsewhere, an example being vaginal thrush.
Malignant otitis externa is a serious complication arising as a result Patients with malignant otitis externa commonly present with
of otitis externa. Infection spreads to the soft tissue in and around the severe pain, much worse than the pain expected from otitis externa.
lateral skull base (necrotising otitis externa). This can spread to involve Otalgia is severe, deep-seated, worse at night and accompanied by
the temporal bone and other bones making up the skull base (skull base otorrhoea, reduced hearing and possible lower cranial nerve weak-
osteomyelitis) with significant morbidity and mortality if inadequately ness. Jaw stiffness and malocclusion may also develop. In advanced
treated. It presents more commonly in those with underlying diabetes infection severe pain above the forehead develops with abducens
mellitus/ the elderly/chronic kidney disease/ the immunocomprom- nerve palsy and signs and symptoms suggestive of meningitis.
ised/ after recent radiotherapy to the head and neck/ following aural
irrigation with tap water in those with underlying risk factors.
Examination
Examination is directed at assessing severity and identifying the underlying
Clinical features cause. Direct visualisation of the external ear and canal should be made,
noting signs of erythema, swelling and discharge. Note any eczematous or
History other changes to surrounding skin, suggesting a dermatological cause, or
History taking in a patient with suspected otitis externa should focus signs of skin trauma. In severe cases, cellulitis of the pinna may be found.
on determining the severity of symptoms and inflammation, as well as Examine the tympanic membrane looking for signs of otitis media, per-
identifying potential causes: foration or retraction of the tympanic membrane. Identifying tympanic
. Severity of symptoms is measured by pain or tenderness on membrane perforation will aid diagnosis and management. This may
moving the ear, itch, hearing loss and degree of discharge not always be possible, due to pain or swelling. Useful indicators of tym-
. Severity of inflammation is determined by identifying patients with panic membrane perforation include (Rosenfeld et al., 2014):
fever, cellulitis, tender lymph nodes, discharge, hearing loss, red- . Patients with recent tympanosotomy tube (within 12 months) and
ness of the ear and narrowing of the external auditory canal no documented closure

2
InnovAiT

. Air blowing from the ear when the nose is pinched . Inadequate delivery of topical treatment
. Tasting medication after ear application . Spread beyond external auditory canal

Examination of the neck may reveal tender cervical lymphaden- . Condition severe and requiring oral antibiotics
opathy. Typically, in localised otitis externa examination may reveal Swabs should be taken under vision, in order to prevent contam-
localised tenderness, swelling and pustular lesions. ination, from the medial aspect of the ear canal. It can be difficult to
In acute otitis externa, tenderness may be found on palpation of the distinguish an organism causing the disease from contaminant organ-
tragus, pinna or both. There may also be otorrhoea, canal oedema,
isms. Ear swabs are important in distinguishing between fungal and
erythema, lymphadenitis, erythema of the tympanic membrane, or cel- bacterial infections. Fungal overgrowth can occur after use of topical
lulitis of the pinna or adjacent skin. Figure 1 shows the typical appear- antimicrobial medications as they suppress the normal bacterial flora.
ance. It may be difficult to distinguish between acute otitis media and
Tympanometry may be helpful to confirm an intact tympanic
acute otitis externa, as erythema affects the tympanic membrane. This is membrane.
important because acute otitis media can require oral antibiotics.
Examination in chronic otitis externa normally reveals the absence
of earwax, dry hypertrophic skin, signs of scratching or generalised
dermatitis and pain on manipulation of ear and canal. Figure 2 shows Management
a typical appearance. Prolonged symptoms cause progressive narrow-
ing of the canal resulting in deafness. On otoscopic examination there Management varies based on the type of otitis externa. There are some
may be signs of fungal infection with white cotton like strands in common themes that apply to all types.
candida, and black or white balls in aspergillus.
In malignant otitis externa, patients may demonstrate otorrhoea, Pain control
exposed bone, granulation and gross oedema, as well as lower cranial
nerve weakness (facial weakness, dysphagia, dysphonia and tongue Good pain control is necessary in all types of otitis externa to allow
movement weakness). They may have a raised temperature. patients to continue normal activities. Use of a suitable visual analogue
scale can help measure the degree of pain (Powell, Kelly, &Williams,
2001). Simple analgesia, such as paracetamol or non-steroidal anti-
inflammatory medications, is usually adequate for managing pain.
Investigation
For more severe pain, codeine may be added with appropriate
Investigation is rarely useful or necessary in otitis externa; however, advice on limiting use and side effects.
expert opinion (Llor, McNulty, & Butler, 2014) suggests taking ear
swabs in certain circumstances: Figure 2. Chronic diffuse otitis externa.
. Treatment failure

. Recurrent or chronic otitis externa

Figure 1. Acute diffuse otitis externa.

Image reproduced with permission from Ariel A Waitzman, MD, Wayne

State University School of Medicine, published by Medscape Drugs &
Diseases (https://emedicine.medscape.com/), Otitis Externa, 2018,
available at: https://emedicine.medscape.com/article/994550-overview Dr P. Marazzi/Science Photo Library.

3
 InnovAiT

Manage potential causative/risk factors can then be reduced to maintain control. If there is no response a trial
of topical antifungal preparation can be tried (BMJ, 2016).
In acute and chronic diffuse otitis externa, it is imperative to identify
the underlying cause for treatment to be successful as detailed
Management of secondary infection
in Table 1. Common causes and their management are explored in
Table 2. Topical therapy
Often in chronic otitis externa, no specific underlying cause can be
Topical therapy should be considered in uncomplicated acute/
found. Empirically, in such cases, a 7-day course of a topical steroid, chronic diffuse otitis externa. There is limited evidence to indicate
perhaps with acetic acid spray, can be tried. The potency of the steroid the best topical treatment (Rosenfeld et al., 2014).
When deciding which preparation to use: severity, likely causative
Table 2. Common causes and their management. organism, patient sensitivity, ear drum status, cost, risk of adverse
Cause Course of action effects, local prescribing guidance, and up-to-date British National
Formulary guidance may be taken into account. Table 3 provides
Diabetes Diabetes control guidance on the various topical therapies available.
A topical antibiotic, with or without a topical steroid, should be
Eczema Should be managed with good
skin care, use of emollients, considered in acute diffuse otitis externa. In randomised trials, use of a
preventing secondary skin topical steroid combined with antimicrobial drops has been shown to
infection and use of topical reduce pain (Van Balen, Smit, Zuithoff, & Verheij, 2003), however,
steroids creams if the sur- other studies have shown no benefits (Psifidis, Nikolaidis & Tsona,
rounding skin is involved 2005).
Topical antibiotics have been found to be safe and effective for
Seborrhoeic Topical antifungal medications acute otitis externa. The high concentration of antibiotic delivered in
dermatitis to reduce the amount of yeast
the ear canal, generally eradicates common pathogens such as
and topical anti-inflammatory
P. aeruginosa and S. aureus, for which oral antibiotics are inactive.
medication to reduce inflam-
mation and itch Topical treatment should be used for 7 days, but if symptoms persist,
use for up to 14 days maximum. Aminoglycosides are contraindicated
Contact dermatitis Removing the sensitising agent in tympanic membrane perforation or with a history of local sensitivity
and applying a topical steroid reaction. Studies have shown that hearing loss may occur after pro-
or other topical anti-inflamma- longed or repeated use of topical drops in tympanic membrane per-
tory agent foration. A non-ototoxic topical medication should be chosen if there
is a risk of tympanic membrane perforation.

Table 3. Topical ear preparations: Otitis externa.

Type of preparation Example(s)
Astringent/ Acidic preparations . Ear calm spray

Steroid preparations . Low potency: Predsoldrops

. High potency: Betnesol, Vist-methasoneÕ drops

Antibiotic preparations . Aminoglycoside: Gentamicin drops

. Non-aminoglycoside: Chloramphenicol 5% drops

Antifungal preparations . Clotrimazole solution

Combined steroid and antibiotic . Quinolone with steroid: CilodexÕ drops

. Aminoglycoside with Steroid:
# Neomycin: Drops: Betnesol N, vista methasone N, otosporin, predsoln
n,Spray: OtomizeÕ
# Gentamicin: GentisoneÕ hc drops
# Framycetin: SofradexÕ drops

Combined steroid and . Clioquinol with corticosteroid: Flumetasone pivalate 0.02%, clioquinol 1%
antibiotic/antifungal

Source: NICE (2016).

4
InnovAiT

Topical quinolones such as Ciprofloxacin or Ofloxacin drops have hand/put in pocket before inserting, to prevent dizziness. The opti-
been shown to improve rates of bacteriological cure, and are mum temperature is room temperature. Ideally patients should lie on
approved for topical treatment with tympanic membrane perforation their side for 3–5 minutes but if not practicable cotton wool with
(Rosenfeld et al., 2014). Topical acetic acid 2% is also a safe and VaselineÕ may be used to prevent drops leaking out for 5 minutes.
effective treatment in mild cases (Kaushik, Malik, & Saeed, 2010). Ideally, the canal is best left open to dry after instillation of the
Neomycin-containing products are the topical preparations that most topical therapy. This prevents moisture trapping and accumulation of
often cause side effects. The National Institute for Health and Clinical infected debris.
Excellence (NICE) does not recommend Chloramphenicol drops as
they can cause dermatitis in 10% of cases (NICE, 2016). Patients should be advised on self-care
In addition to bacterial infections, fungal infections can be found in measures
chronic otitis externa and this can be difficult to manage. If this is
evident, consideration should be given to a topical antifungal prepar- Localised otitis externa is most commonly managed with a warm flan-
ation such as, Clotrimazole 1% solution or Clioquinol and corticoster- nel on the area.
oid, e.g. Locorten vioform, acetic acid 2% spray (unlicensed use). Self-care measures for all patients with otitis externa are aimed at ensur-
Side effects of topical therapies include pruritus, site reaction, rash ing water does not accumulate in the external canal (Rosenfeld et al., 2014).
discomfort, otalgia, dizziness, vertigo, super-infection and reduced This enables development of a healthy skin barrier. Stress the importance
hearing. Fungal infection can be a side effect of topical antimicrobial of water protection while otitis externa is present. We usually advise
agents with repeated courses of treatment. patients to use cotton wool soaked in VaselineÕ to plug the outer ear
canal while taking a shower. If the ear canal gets wet the otitis externa will
Oral antibiotics not resolve. Table 4 provides details of self-care measures.

Oral antibiotics are not often necessary, as most cases of localised

otitis externa are self-limiting and topical therapy is the mainstay of Follow-up
treatment for diffuse otitis externa. Oral antibiotics can cause rash,
Follow-up is generally unnecessary in mild cases of otitis externa.
vomiting, diarrhoea, vomiting and allergic reactions.
Patients with any type of otitis externa who have any of the following
There are situations in which a 7-day course of oral Flucloxacillin or
features/risk factors should be reviewed:
Clarithromycin in penicillin allergy is recommended as shown below:
. Severe otitis externa with accompanying cellulitis
Localised acute otitis externa:
. Severe infection/ systemic signs, e.g. fever . Wax accumulation

. Cellulitis spreads beyond the ear canal . Narrowed ear canals

. Underlying risk factors, such as diabetes, or becoming

immunocompromised
Table 4. Self-care advice.
. When the ear canal is occluded and a wick may be necessary
Objective Action
A course of oral Ciprofloxacin may be needed when it is thought
pseudomonal infections are involved or the patient has underlying Avoid damage to Avoid using cotton buds in the ear;
diabetes or is immunocompromised. external canal wax and debris should only be
Acute otitis externa can be a result of acute otitis media. It should be
removed by professionals
noted that patients with concurrent acute otitis media and acute otitis
Keep ears clean Use ear plugs and a cap when
externa need treatment for both conditions (Lieberthal et al., 2004). and dry swimming/avoid watersports for
7–10 days in active infection/dry
ears with a hair dryer at lowest
Patient education setting after water activities
including hair washing/keep water
At all times patients should be empowered to manage their own
out of ear when showering/
health. Patients should be educated on:
bathing
. Application of ear drops
. Self-care advice Manage underlying If allergy to ear plugs seek alter-
skin conditions native/control underlying condi-
. When to return
tion, e.g. psoriasis/eczema

Preventative Over-the-counter acidifying ear

Application of ear drops strategies drops/spray before swimming
after swimming and before
When administering eardrops it is preferable for an assistant to clean bedtime
exudate from the ear. The drops should be warmed by holding in the

5
 InnovAiT

. If symptoms do not improve/get worse Box 1. Why otitis externa may have failed to resolve.
. Underlying conditions, e.g. diabetes, immunocompromised . Compliance and technique with medication:
Patients diagnosed as having localised otitis externa should be
# Patient education should be advised
followed up if an oral antibiotic was prescribed. In acute otitis externa,
symptoms of otalgia, itch, and fullness should improve in 48–72 hours . Obstruction of the ear canal:
from starting topical therapy. If pain does not improve within this
# Patency of the ear canal should be checked to ensure
timeframe, patients should be reviewed. Clinical resolution is found
that oedema or debris does not obstruct delivery of
in 65–90% of patients in 7–10 days regardless of the topical medication topical treatment. If patency is not maintained referral
used. Certainly, follow-up is necessary if symptoms have failed to for aural toileting / otowick insertion is required
completely resolve after 2 weeks of treatment (Rosenfeld et al.,
2014). In chronic otitis externa, patients should be reviewed after a . Persistent underlying disease process? For example,
course of treatment.
poor diabetic control/ dermatoses:
We see a lot of patients with severe otitis externa following ear # This should be managed based on potential cause.
syringing which then develop into malignant otitis externa. In patients Patch testing and dermatology referral may be con-
with risk factors for malignant otitis externa please follow them up to sidered if there is a failure to resolve in those under-
ensure otitis externa is not developing and start antibiotic eardrops if lying dermatological cases
this is the case. If the treatment with eardrops is not working after 5
. Microbiological factors:
days or so then consider early/ urgent referral to emergency ENT
clinic for review. Prevention of malignant otitis externa is highly # Consider an ear swab to identify underlying causative
important. More Ciprofloxacin resistant infections are being identified. organism in treatment failure. If felt to be appropriate,
Do not treat with ciprofloxacin drops initially, unless microbiological a switch to an alternative therapy may be necessary
sensitivity is confirmed. Swabs are becoming more useful as antibiotic
# Fungi may present after repeated courses of anti-
resistance is becoming more problematic, especially in relation to biotics, due to alteration of the normal ear flora.
malignant otitis externa. Treatment with topical antifungals may be necessary

. Misdiagnosis?
Treatment failure # It is not uncommon to get the diagnosis wrong, so if
There may be a number of reasons why otitis externa may not be you are faced with otalgia/ otorrhoea failing to resolve
resolving. Box 1 provides a checklist to consider when faced with
it is worth revisiting your history and diagnosis
otitis externa that has failed to resolve. # Other underlying causes may be: Acute otitis media,
neoplasm, foreign body, trauma, earwax, temporo-
mandibular joint pain, cholesteatoma, mastoiditis,
Referral to secondary care malignant otitis externa, referred pain sphenoid
sinus, teeth, neck, throat, viral infections, skin
If malignant otitis externa is suspected, urgent same-day referral to conditions
secondary care is needed. With treatment, the mortality rate is less
than 15%.
. Ongoing treatment after 2–3 months
Referral of patients with severe localised otitis externa to second-
ary care should be made if incision and drainage are not available in
Complications
primary care, with an inadequate response to antibiotics, or when
there is a spreading cellulitis outside the external canal. Inadequately managing otitis externa can result in complications such
In diffuse otitis externa referral should be made in the following as (Rosenfield et al., 2014):
situations: . Otitis externa:
. Failure to respond to appropriate treatment # Abscess formation, chronic otitis externa, chondritis, parotitis,
auricular cellulitis, fibrosis and stenosis of the canal leading to
. Otowick or micro suction is required conductive hearing loss, tympanic membrane perforation,
malignant otitis externa, myringitis
. Severe symptoms, extreme pain
. Malignant otitis externa:
. Cellulitis is extending outside the canal
# Facial palsy, meningitis
. Contact sensitivity is suspected and patch testing may be required
in chronic otitis externa

6
InnovAiT

. Patients with severe symptoms or underlying risk factors

KEY POINTS should be followed up and may need referral
. Malignant otitis externa is a complication of otitis ex-
. Thorough clinical assessment can identify the type and
terna, has a significant mortality and requires urgent
underlying cause of otitis externa
same-day referral
. Take swabs from the external auditory meatus in
patients unresponsive to initial treatment
. Patient education and self-care are important in the
management of otitis externa ORCID iD
. Oral antibiotics are often not indicated Dr Emma Dickson http://orcid.org/0000-0002-2718-3543

Acknowledgement
We would like to thank Dr Helen Carslaw for her help with the
writing of this article under the InnovAiT ‘buddy’ scheme.

References and further information

Agius, A. M., Pickles, J. M., & Burch, K. L. (1992). A M., . . . Wald, E. (2004). Pediatrics diagnosis and difference in visual analog pain score for children. Rowlands, S., Devalia, H., Smith, C., Hubbard, R.,
prospective study of otitis externa. Clinical management of acute otitis media. Pediatrics, Annals of Emergency Medicine, 37(1), 28–31. doi: & Dean, A. (2001). Otitis externa in UK general
Otolaryngology and Allied Sciences, 17(2), 113, 1451–1465. Retrieved from http://emer- 10.1067/mem.2001.111517 practice: A survey using the UK general practice
150–154. Retrieved from www.unboundmedici- gency.med.ufl.edu/files/2013/02/Diagnosis-and- research database. British Journal of General
Psifidis, A., Nikolaidis, P., & Tsona, A. (2005). The
ne.com/medline/citation/1587031/A_prospective_ Management-of-Acute-Otitis-Media.pdf Practice, 51(468), 533–538. Retrieved from www.
efficacy and safety of local ciprofloxacin in
study_of_otitis_externa ncbi.nlm.nih.gov/pmc/articles/PMC1314044/pdf/
Lindisfarne, E., Berwick, J., & Das, P. (2012). patients with external otitis: A randomized com-
BMJ. (2016). Best practice: Otitis externa. Clinical review: Acute otitis externa: A clinical 11462312.pdf
parative study. Mediterranean Journal of Otology
Retrieved from http://bestpractice.bmj.com/best- review of the aetiology, diagnosis and manage- and Audiology, 1, 20–23. Retrieved from http:// Van Balen, F.A., Smit, W. M., Zuithoff, N. P., &
practice/monograph/40.html ment of otitis externa. Retrieved from www.gpon- docplayer.net/49994935-Volume-1-issue-3-year- Verheij, T. J. (2003). Clinical efficacy of three
line.com/clinical-review-acute-otitis-externa/ear- 2005.html common treatments in acute otitis externa in pri-
British Medical Association and Royal
nose-and-throat/article/1120743 mary care: Randomised controlled trial. BMJ,
Pharmaceutical Society of Great Britain. (2017). RCGP. Clinical module 3.15: Care of people with
British national formulary 74. London, UK: Llor, C., McNulty, C. A., & Butler, C. C. (2014). 327(7425), 1201–1205. doi: 10.1136/
ENT oral and facial problems. Retrieved from
British Medical Association and Royal Ordering and interpreting ear swabs in otitis ex- bmj.327.7425.1201
www.rcgp.org.uk/training-exams/gp-curriculum-
Pharmaceutical Society of Great Britain terna. BMJ, 349, g5259. doi: 10.1136/bmj. g5259
overview/online-curriculum/applying-clinical- Walshe, P., Cleary, M., McConn, W. R., & Walsh,
Gleeson, M. J. (Ed.) (2008). Risk factors: NICE. (2016). Clinical knowledge summary: Otitis knowledge-section-2/3-15-ent-oral-and-facial- M. (2002). Malignant otitis externa – a high index
Otolaryngology, head and neck surgery. London, externa. Retrieved from https://cks.nice.org.uk/ problems.aspx of suspicion is still needed for diagnosis. Irish
UK: Hodder Arnold otitis-externa Medical Journal, 95(1), 14–16
Rosenfeld, R. M., Schwartz, S. R., Cannon, C. R.,
Kaushik, M., and Saeed, S. R. (2010). Interventions Osguthorpe, J. D., & Nielsen, D. R. (2006). Otitis Roland, P. S., Simon, G. R., Kumar, K. Wipperman, J. (2014). Otitis externa. Primary
for acute otitis externa. Cochrane Database of externa: Review and clinical update. American A., . . . Robertson, P. J. (2014). Clinical practice Care, 41(1), 1–9. doi: 10.1016/j.pop.2013.10.001
Systematic Reviews, 1, art. no.: CD004740. doi: Family Physician, 74(9), 1510–1516. Retrieved guideline: Acute otitis externa. Otolaryngology –
10.1002/14651858.CD004740.pub2 from www.aafp.org/afp/2006/1101/p1510.html Head and Neck Surgery, 150(1 Suppl), s1–s24.
Lieberthal, A. S., Ganiats, T. G., Cox, E. O., Powell, C. V., Kelly, A. M., & Williams, A. (2001). doi.org:10.1177/0194599813517083
Culpepper Mahoney, M., Miller, D., Runyan, D. Determining the minimum clinically significant