NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide).

Some of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

Otitis externa is inflammation, with or without infection, of the external ear canal. Many cases recover after thorough cleansing of the external ear canal by suction or dry mopping.

Caution is advised to ensure that the repeated episodes of irritation and discharge represent genuine otitis externa, and not an underlying chronic otitis media with perforation.

The most effective method is to introduce a ribbon gauze dressing soaked with corticosteroid ear drops or with an astringent such as aluminium acetate solution.

Ear swabs for culture should be reserved for treatment failures or chronic cases. They may be carried out using a urethral swab (i.e. narrow cotton-tipped swab on a wire, not a 'throat' swab).

When considering specialist referral see: Western Devon CRG: Otitis Externa and South Devon and Torbay CRG: Otitis Externa

Chronic or recurrent otitis externa

Some patients present with frequent otitis externa that may be related to water sports, vigorous ear cleaning or chronic dermatitis. For patients who develop itching, pain or irritation of the ear canals after exposure to water, an acetic acid (vinegar) and alcohol based ear wash can be very effective in avoiding development of infective and more severe otitis externa by immediate use after water has entered the ears.

Acetic acid 2%

• Ear spray (£4.92 = 5ml)

Indications

• Superficial infections of the external auditory canal

Dose

• One spray every 8 hours for a maximum of 7 days

Notes

1. Acetic acid 2% solution is antifungal and antibacterial and may be useful for mild otitis externa.
2. The proprietary Ear Calm spray may be obtained over the counter at pharmacies.

Anti-inflammatory preparations

Early brief treatment (as short as 48 hours) of exacerbations of chronic eczematous otitis externa with steroid ear drops may be helpful; however, avoid prolonged use of topical steroids. Microsuction should be considered where there is a build-up of debris or an inadequate response to initial topical treatment.

Betamethasone

• Ear drops 0.1% (£2.32 = 10ml)

Indications

• Eczematous inflammation in otitis externa

Dose

• Apply 2–3 drops every 2–3 hours; reduce frequency when relief obtained

Prednisolone sodium phosphate

• Ear drops 0.5% (£2.57 = 10ml)

Indications

• Eczematous inflammation in otitis externa

Dose

• Apply 2–3 drops every 2–3 hours; reduce frequency when relief obtained

Anti-infective preparations

Infective otitis externa may be treated with aural antibiotics and anti-inflammatory drops. There are no indications for systemic treatment unless systemic symptoms or local spread leading to oedema, cellulitis and erysipelas. Solutions containing a corticosteroid agent are useful for treating cases with inflammation and eczema.

Consideration should be given to the fact that pseudomonal resistance to aminoglycoside antibiotics is growing.

In view of reports of ototoxicity, manufacturer's contra-indicate treatment with a topical aminoglycoside or polymixins in those with a perforated tympanic membrane (eardrum) or patent grommet.

If infection is present a topical anti-infective agent that is not usually used systemically (e.g. neomycin or clioquinol) may be used, but for about a week as excessive use may result in fungal infections. Fungal infections may be difficult to treat and require specialist referral (Refer to below).

Flumetasone 0.02% / Clioquinol 1%

• Ear drops (£11.34 = 7.5ml)

Indications

• Mild bacterial or fungal infections in otitis externa
• Eczematous inflammation in otitis externa

Dose

• Adult and child over 2 years: Apply 2–3 drops into the ear every 12hours for 7–10 days

Notes

1. Combines the anti-fungal and anti-bacterial properties of clioquinol with the anti-inflammatory activity of flumetasone pivalate
2. Do not use for more than 7-10 days to prevent fungal overgrowth or resistance
3. May cause stinging and can stain clothing
4. Oil-based ear drops and cannot be easily used with an ear wick unless the wick is expanded by a water-based drops first
5. Manufacturer advises avoid in perforated tympanic membrane (but may be used by specialist for short periods)

Otomize

(Combination of dexamethasone 0.1%, neomycin sulphate 3250units/ml, glacial acetic acid 2%)

• Ear Spray: (£3.27 = 5ml)

Indications and dose

• Adults and children over 2 years: Eczematous inflammation in otitis externa
  • Apply1 metered spray 3 times daily

Notes

1. Contraindicated in perforated tympanic membrane although may be used by specialists

Ciprofloxacin 0.3% / Dexamethasone 0.1%

• Ear drops (£6.12 = 5ml)

Indications and dose

• Acute otitis externa
  • Adults and children over 1 year of age: Instil four drops in the affected ear(s) twice a day for 7 days

Notes

1. May be preferred in cases of tympanic perforation (unlicensed indication)
2. The manufacturer advises further evaluation of underlying conditions if otorrhoea persists after a full course, or if at least two episodes of otorrhoea occur within 6 months.

Gentamicin 0.3% / Hydrocortisone 1%

• Ear drops: (£33.26 = 10ml)

Indications and dose

• Adult and child: Eczematous inflammation in otitis externa
  • Apply 2–4 drops every 6-8 hours and at night for 7-10 days

Notes

1. Contraindicated in perforated tympanic membrane although may be used by specialists

Gentamicin

• Ear drop 0.3% (£20.00 = 10ml)

Indications and dose

• Adult and child: Bacterial infection in otitis externa
  • Apply 2–4 drops every 6-8 hours and at night for 7-10 days

Notes

1. Contraindicated in perforated tympanic membrane although may be used by specialists.

Ceftazidime

• Ear drops 5% (unlicensed preparation)

Sofradex

(combination of dexamethasone 0.05%, framycetin sulphate 0.5%,gramicidin 0.005%)

• Ear drops: 8ml

Notes

1. Sofradex is considered to be less suitable for prescribing. Sofradex is reserved for use in hospital only where other preparations are not effective.

Kenacomb Otic

(combination of triamcinolone acetonide 0.1%, neomycin sulphate 0.25%, gramicidin 0.0025%, nystatin 100,000 units/g)

• Ear ointment (unlicensed preparation)

Fungal infection

Fungal external ear infections are not unusual and may be the result of over-use of aural and oral antibiotics. They may be difficult to treat; specialist referral should be considered if treatment with clotrimazole ear drops fails to resolve symptoms.

Clotrimazole

• Solution 1% (£2.53 = 20ml)

Indications and dose

• Adult and child: Initial management of fungal infection (before referral to secondary care)
  • Apply 2–3 times daily continuing for at least 14 days after disappearance of infection