Clinical practice guideline: acute otitis externa

Otolaryngol Head Neck Surg. 2014 Feb;150(1 Suppl):S1-S24. doi: 10.1177/0194599813517083.


Objective: This clinical practice guideline is an update and replacement for an earlier guideline published in 2006 by the American Academy of Otolaryngology-Head and Neck Surgery Foundation. This update provides evidence-based recommendations to manage acute otitis externa (AOE), defined as diffuse inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. The variations in management of AOE and the importance of accurate diagnosis suggest a need for updating the clinical practice guideline. The primary outcome considered in this guideline is clinical resolution of AOE.

Purpose: The primary purpose of the original guideline was to promote appropriate use of oral and topical antimicrobials for AOE and to highlight the need for adequate pain relief. An updated guideline is needed because of new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group. The target patient is aged 2 years or older with diffuse AOE. Differential diagnosis will be discussed, but recommendations for management will be limited to diffuse AOE, which is almost exclusively a bacterial infection. This guideline is intended for primary care and specialist clinicians, including otolaryngologists-head and neck surgeons, pediatricians, family physicians, emergency physicians, internists, nurse practitioners, and physician assistants. This guideline is applicable in any setting in which patients with diffuse AOE would be identified, monitored, or managed.

Action statements: The development group made strong recommendations that (1) clinicians should assess patients with AOE for pain and recommend analgesic treatment based on the severity of pain and (2) clinicians should not prescribe systemic antimicrobials as initial therapy for diffuse, uncomplicated AOE unless there is extension outside the ear canal or the presence of specific host factors that would indicate a need for systemic therapy. The development group made recommendations that (1) clinicians should distinguish diffuse AOE from other causes of otalgia, otorrhea, and inflammation of the external ear canal; (2) clinicians should assess the patient with diffuse AOE for factors that modify management (nonintact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, prior radiotherapy); (3) clinicians should prescribe topical preparations for initial therapy of diffuse, uncomplicated AOE; (4) clinicians should enhance the delivery of topical drops by informing the patient how to administer topical drops and by performing aural toilet, placing a wick, or both, when the ear canal is obstructed; (5) clinicians should prescribe a non-ototoxic preparation when the patient has a known or suspected perforation of the tympanic membrane, including a tympanostomy tube; and (6) clinicians should reassess the patient who fails to respond to the initial therapeutic option within 48 to 72 hours [corrected] to confirm the diagnosis of diffuse AOE and to exclude other causes of illness.

Keywords: acute otitis externa; clinical practice guideline; meta-analysis; randomized controlled trials; topical antimicrobial therapy.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Acute Disease
  • Administration, Oral
  • Administration, Topical
  • Adolescent
  • Adult
  • Analgesics / therapeutic use
  • Anti-Bacterial Agents / therapeutic use*
  • Child
  • Child, Preschool
  • Evidence-Based Medicine
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Otitis Externa / complications
  • Otitis Externa / diagnosis
  • Otitis Externa / drug therapy*
  • Otoscopy / methods
  • Pain / drug therapy*
  • Pain / etiology
  • Pain / physiopathology
  • Pain Measurement
  • Practice Guidelines as Topic*
  • Randomized Controlled Trials as Topic
  • Risk Assessment
  • Severity of Illness Index
  • Treatment Outcome
  • Young Adult


  • Analgesics
  • Anti-Bacterial Agents