1. Differential diagnosis:

Clinicians should distinguish diffuse acute otitis externa (AOE) from other causes of otalgia, otorrhea, and inflammation of the external ear canal.

Strong recommendation

Moderate Quality Evidence (based on observational studies with a preponderance of benefit over risk)^2,3

2. Modifying factors:

Clinicians should assess the patient with diffuse AOE for factors that modify management (non-intact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, prior radiotherapy).

➡️Strong recommendation

Moderate Quality Evidence (based on observational studies with a preponderance of benefit over risk)^4-8

3. Pain management:

The clinician should assess patients with AOE for pain and recommend analgesic treatment based on the severity of pain..

➡️Strong Recommendation

Hihg Quality Evidence (based on well-designed randomized trials with a preponderance of benefit over harm)^9-19

4. Systemic antimicrobials:

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.

➡️Strong Recommendation

High Quality Evidence (based on randomized controlled trials

with minor limitations and a preponderance of benefit over harm)^20-25

5. Topical therapy:

Clinicians should use topical preparations for initial therapy of diffuse, uncomplicated AOE.

➡️Strong recommendation

High Quality Evidence (based on randomized trials with some heterogeneity and a preponderance of benefit over harm)^26-28

6. Drug delivery:

Clinicians should inform patients how to administer topical drops and should enhance delivery of topical drops when the ear canal is obstructed by performing aural toilet, placing a wick, or both.

➡️Strong Recommendation

High Quality Evidence (based on observational studies with a preponderance of benefit over harm)^29.30

7. Nonintact tympanic membrane:

When the patient has a known or suspected perforation of the tympanic membrane, including a tympanostomy tube, the clinician should recommend a non-ototoxic topical preparation.

➡️Conditional recommendation

Moderate Quality Evidence (based on reasoning from first principles and on exceptional circumstances in which validating studies cannot be performed and there is a preponderance of benefit over harm.)^31-35

8. Outcome assessment:

If the patient fails to respond to the initial therapeutic option within 48 to 72 hours, the clinician should reassess the patient to confirm the diagnosis of diffuse AOE and to exclude other causes of illness.

➡️Conditional Recommendation

Moderate Quality Evidence (based on observational studies and a preponderance of benefit over harm)^36-38

Clinical Indicators for Monitoring