Mastering Acute Otitis Externa Guidelines for PLAB 2 Success

Mastering Acute Otitis Externa Management Guidelines for PLAB 2 OSCE Success

Acute Otitis Externa (AOE), often dubbed 'Swimmer's Ear,' is one of the most common ENT presentations you will encounter in primary care and emergency departments in the UK. For the PLAB 2 OSCE, mastering the consultation—from history taking and examination findings to providing clear, guideline-compliant management—is essential.

This guide breaks down the core clinical guidelines for AOE management, ensuring you demonstrate safe, effective, and patient-centered care.

1. The PLAB 2 Approach: Diagnosis and Communication

In a PLAB 2 station, a patient presenting with ear pain and discharge requires a focused but comprehensive approach. Your diagnostic ability relies heavily on history and otoscopy.

Key History Points:

• Pain: Often severe, made worse by moving the pinna or chewing (a key differentiator from Otitis Media).

• Discharge: Usually thick, white, or yellow.

• Risk Factors: Recent swimming, use of cotton buds, trauma, or underlying skin conditions (eczema, psoriasis).

• Red Flags: Unilateral facial weakness, dizziness (vertigo), high fever, severe systemic illness, or pain disproportionate to findings (especially in diabetics/immunocompromised).

Otoscopy Findings:

• Swollen, erythematous external auditory canal.

• Often tender upon insertion of the speculum.

• Discharge/debris present in the canal.

• The tympanic membrane (TM) is usually visible and normal, differentiating it from Otitis Media.

PLAB 2 Tip: Always check for tragal tenderness or pain on moving the pinna. This is a highly characteristic sign of AOE.

2. Core UK Management Guidelines for Uncomplicated AOE

Guideline compliance (often based on NICE or local formulary advice) is mandatory for achieving a high score in the PLAB 2 OSCE management domains.

A. General & Conservative Measures

These initial steps are crucial for symptomatic relief and preventing recurrence:

1. Analgesia: Advise regular Paracetamol and/or Ibuprofen.

2. Aural Hygiene (Aural Toilet): While complex aural toilet is often performed by specialist nurses/ENT, advise the patient to keep the ear clean and dry.

3. Water Avoidance: Crucial advice. The patient must avoid getting water in the ear canal (e.g., swimming, showering) until symptoms resolve. Use cotton wool covered in petroleum jelly during washing.

4. Avoidance of Trauma: Stop scratching, poking, or using cotton buds/in-ear devices (like headphones/hearing aids) until recovery.

B. Topical Pharmacological Treatment

Topical preparations are the mainstay of treatment for AOE, as they deliver high concentrations of medication directly to the infection site while minimizing systemic side effects.

First-Line Treatment: A combination preparation containing both an antibiotic and a corticosteroid.

• Duration: Typically prescribed for 7 to 14 days.

• Administration: Emphasize the correct application technique (lying down for 5 minutes after drops, warming the bottle slightly). If the canal is very swollen, a wick may be needed (referral usually required).

C. When to Consider Oral Antibiotics

Oral antibiotics are NOT routinely indicated for uncomplicated AOE. They are reserved for specific situations:

• Spread of infection beyond the ear canal (cellulitis of the pinna/face).

• Systemic signs of infection (e.g., high fever, malaise).

• Patients who are severely immunocompromised or diabetic (due to the risk of Malignant Otitis Externa).

3. Addressing Specific Management Challenges

Fungal Otitis Externa (Otomycosis)

• Clues: Often persistent symptoms despite standard topical antibiotics; appearance of white/black mycelial debris (like damp cotton wool).

• Management: Requires topical antifungal treatment (e.g., Clotrimazole 1% solution) after thorough aural toilet to remove debris.

Malignant Otitis Externa (MOE)

This is a life-threatening necrotising infection of the external ear canal and skull base, primarily seen in elderly, diabetic, or immunocompromised patients. This is a red flag and requires immediate hospital admission.

• Clues: Severe, deep-seated pain disproportionate to findings; granulation tissue in the inferior posterior canal; systemic illness; possible facial nerve palsy (late sign).

• Action: Immediate referral/admission for IV antibiotics (often Ciprofloxacin) and specialist ENT/Infectious Diseases input.

4. Safety Netting and Follow-Up (The PLAB 2 Communication Score)

Excellent safety netting ensures patient safety and scores highly in the OSCE communication domain.

1. Expected Improvement: "You should start feeling better within 48–72 hours, but complete resolution may take up to two weeks."

2. When to Return/Seek Urgent Care:

   • If pain worsens or spreads to the jaw/face.

   • If you develop swelling behind the ear (mastoiditis concerns).

   • If you become systemically unwell (high fever, dizziness, confusion).

   • If the ear canal becomes completely blocked, preventing drops from entering.

3. Follow-up: Arrange a follow-up appointment if symptoms have not improved significantly within 7 days to reassess the diagnosis or consider specialist referral (e.g., if a fungal infection is suspected, or for aural toilet).

By mastering the differential diagnosis, adhering to the topical treatment approach, and prioritizing safety netting, you will confidently tackle Acute Otitis Externa scenarios in your PLAB 2 OSCE.