The diagnosis of diffuse AOE requires rapid onset (generally within 48 hours) in the past 3 weeks of symptoms and signs of ear canal inflammation, as detailed in Table 4. A hallmark sign of diffuse AOE is tenderness of the tragus, pinna, or both that is often intense and disproportionate to what might be expected based on visual inspection.

The continued variations in managing AOE and the importance of accurate diagnosis suggest a need for this evidence-based clinical practice guideline. Failure to distinguish AOE from other causes of “the draining ear” (eg, chronic external otitis, malignant otitis externa, middle ear disease, cholesteatoma) may prolong morbidity or cause serious complications.

Because topical therapy is efficacious, systemic antibiotics are often prescribed inappropriately. When topical therapy is prescribed, confusion exists about whether to use an antiseptic (eg, acetic acid), antibiotic, corticosteroid, or a combination product. Antibiotic choice is controversial, particularly regarding the role of newer quinolone drops. Lastly, the optimal methods for cleaning the ear canal (aural toilet) and drug delivery are defined.

The primary outcome considered in this guideline is clinical resolution of AOE, which implies resolution of all presenting signs and symptoms (eg, pain, fever, otorrhea). Additional outcomes considered include minimizing the use of ineffective treatments; eradicating pathogens; minimizing recurrence, cost, complications, and adverse events; maximizing the health-related quality of life of individuals afflicted with AOE; increasing patient satisfaction ; and permitting the continued use of necessary hearing aids. The relatively high incidence of AOE and the diversity of interventions in practice (Table 5) make AOE an important condition for the use of an up-to-date, evidence-based practice guideline.

➡️Purpose

The primary purpose of the guideline is to promote appropriate use of oral and topical antimicrobials for AOE and to highlight the need for adequate pain relief.

This guideline does not apply to children younger than 2 years or to patients of any age with chronic or malignant (progressive necrotizing) otitis externa. AOE is uncommon before 2 years of age, and very limited evidence exists regarding treatment or outcomes in this age group. Although the differential diagnosis of the “draining ear” will be discussed, recommendations for management will be limited to diffuse AOE, which is almost exclusively a bacterial infection. The following conditions will be briefly discussed but not considered in detail: furunculosis (localized AOE), otomycosis, herpes zoster oticus (Ramsay Hunt syndrome), and contact dermatitis.

➡️The target audience

The 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. The guideline is applicable to any setting in which children, adolescents, or adults with diffuse AOE would be identified, monitored, or managed.