Otitis externa (outer ear infection): symptoms, treatment and how long it lasts

Otitis externa sometimes gets better without treatment, but NHS inform says it can take several weeks. Your pharmacist or GP can prescribe ear drops that usually improve symptoms within a few days, and NHS inform says drops are usually used several times a day for about a week. Your GP may refer you to a specialist if symptoms are severe or treatment does not help.

Treatment depends on what is causing the inflammation. The NHS says a pharmacist or GP may give antibiotic tablets or eardrops, antifungal or steroid eardrops, or painkilling eardrops, and that if there is a spot or boil in the ear a GP may pierce it with a needle to drain the pus. Pain can be eased with paracetamol or ibuprofen (children under 16 should not take aspirin), and discharge can be wiped away with cotton wool.

NICE CKS adds that management includes avoiding trauma to the ear, keeping it clean and dry, considering over-the-counter acetic acid 2% ear drops or spray, treating any underlying cause, and considering "aural toilet", the careful cleaning of debris from the canal, when there is discharge or debris. A topical antibiotic or antifungal, with or without a steroid, may be prescribed depending on clinical judgement.

NHS inform adds that if the condition is caused by a boil in the ear, placing a warm flannel or cloth over the affected ear can help it heal faster, and that pain relief such as paracetamol or ibuprofen can ease ear pain, though it is not suitable for everyone so check the leaflet or ask a pharmacist.

• Do not put cotton buds, fingers or other objects in your ear.

• Do not let water or shampoo get in the ear, and do not swim while you have an ear infection.

• Do not use decongestants or antihistamines: the NHS says there is no evidence they help ear infections.

The NHS points out that eardrops may not work if they are not used correctly, which is a common reason for slow improvement. Its guidance is to remove any discharge or earwax first using cotton wool, lie on your side with the affected ear facing up, put the drops in, and gently pull and push the ear to work them down. Stay lying down for 5 minutes so the drops do not run out.

NICE CKS notes that follow-up should be arranged if symptoms are persistent or severe, if the person is immunocompromised, or if a narrowed or blocked canal makes topical treatment hard to deliver. In those situations, specialist ear, nose and throat advice may be needed to clean the canal so that drops can reach the skin.

NHS inform lists the symptoms of otitis externa below. It says usually only one ear is affected, and that with treatment the symptoms should clear up within a few days. NICE CKS says acute otitis externa should be suspected with itch, pain or discharge from the ear canal, hearing loss, tenderness when the tragus or outer ear is touched, and a red, swollen canal.

• Ear pain.

• Itching and irritation in and around the ear canal.

• Redness and swelling of the outer ear and ear canal.

• A feeling of pressure and fullness inside the ear.

• Scaly skin in and around the ear canal, which may peel off.

• Discharge from the ear, thin and watery or thick and pus-like.

• Tenderness when you move your ear or jaw, and swollen sore glands in the throat.

• Some hearing loss.

The ear has three parts, and infections are named after the one affected. NHS information describes outer ear infection, otitis externa, as affecting the ear canal, and distinguishes it from middle ear infection, which affects the space behind the eardrum and is usually seen in children, and from inner ear infection, which involves the labyrinth and balance system.

NICE Clinical Knowledge Summaries describe otitis externa as diffuse inflammation of the skin and deeper tissue of the ear canal, which may also involve the outer ear flap or the eardrum. It is classed as acute or chronic: chronic otitis externa is inflammation that has lasted longer than 3 months.

The NHS says outer ear infections are caused by something irritating the ear canal, such as eczema, water or earplugs, or by a fungal or bacterial infection. NICE CKS adds more detail on the organisms and associations:

• Acute cases are typically bacterial, most often Pseudomonas aeruginosa or Staphylococcus aureus.

• Chronic cases may involve fungi such as Aspergillus or Candida albicans, and long-term use of topical antibiotic or steroid drops can itself encourage fungal infection.

• Underlying skin conditions including contact dermatitis, injury to the canal, a foreign body or blockage, and water exposure are all associated with acute otitis externa.

• Diabetes and other causes of reduced immunity are associated with chronic and more serious forms.

NHS inform says that with treatment the symptoms should clear within a few days, that otitis externa sometimes gets better without treatment but can take several weeks, and that some cases can persist for several months or longer. NICE CKS classes it as acute, lasting 3 weeks or less, or chronic, lasting longer than 3 months.

The NHS says most ear infections generally clear up within 3 days, although sometimes symptoms last up to a week, and to see a GP if earache has not improved after 3 days or infections keep coming back. NHS inform says that if you have otitis externa often and treatment does not help, your GP may take a swab of the inside of your ear to check what type of infection you have.

The NHS lists symptoms of ear infection that include pain inside the ear, a high temperature, difficulty hearing, discharge, a feeling of pressure or fullness, and itching, irritation or scaly skin in and around the ear. Symptoms usually start quickly.

NICE CKS says acute otitis externa should be suspected with itch, pain or discharge from the ear canal, hearing loss, tenderness when the small flap in front of the ear canal (the tragus) or the outer ear is touched, and a red, swollen canal. In the chronic form the typical picture is itching with dry, scaly or red moist skin in the canal.

The clinician asks about onset, severity, previous episodes and ear surgery, then examines the canal, outer ear and nearby lymph nodes, often with an otoscope, an instrument with a light and magnifying glass. An ear swab for bacterial and fungal testing is arranged when treatment fails or the infection is severe, recurrent or chronic, when the canal is blocked, or when cellulitis extends beyond the canal.

The NHS says a pharmacist can give children aged 1 to 17 years the same treatments as a GP for an ear infection, and that you should see a GP if a child under 12 months old may have an ear infection. NHS information describes outer ear infection as something that can affect both children and adults.

None of the sources reviewed describe otitis externa as spread from person to person. It is described as caused by irritation, water, bacteria or fungi in the ear canal. The NHS does advise anyone with a high temperature or who feels unwell to stay at home and avoid contact with other people until they feel better.

Most outer ear infections are minor, but one form is not. NICE CKS describes necrotising (previously called malignant) otitis externa as a potentially life-threatening progressive infection of the ear canal that can spread to the temporal bone, part of the skull beside the ear, and nearby structures. It is associated with diabetes and other causes of reduced immunity, older age, radiotherapy to the head or neck, and previous ear surgery or irrigation. Features include unrelenting pain, pus-like discharge, feeling generally unwell, hearing loss, granulation tissue in the canal and sometimes facial nerve weakness.

The NHS advises asking for an urgent GP appointment or help from NHS 111 if you or your child have ear infection symptoms and also feel generally unwell, have a very high temperature or feel hot, cold or shivery, have swelling around the ear, fluid coming out of the ear, a change in hearing or new hearing loss, or feel sick, dizzy or have a severe sore throat. The same applies if you have diabetes, a heart, lung, kidney or neurological condition, or a weakened immune system. A GP appointment is advised if earache has not improved after 3 days or infections keep returning.

The NHS says you cannot always prevent ear infections, but sensible steps help. Use earplugs or a swimming hat over the ears when you swim, avoid getting water or shampoo into the ears in the shower or bath, and consider cotton wool smeared with petroleum jelly in the ear while showering if water is hard to keep out. Treating conditions that affect the ear, such as eczema or an allergy to hearing aids, also reduces the chance of a repeat episode.

People who keep getting outer ear infections may be referred to ear, nose and throat services, where microsuction cleaning and swab testing can establish whether a fungal cause, a skin condition or a hearing aid problem is responsible.