When to refer

Refer individuals:

• Who have compromised immunity, severe infection, high risk of severe infection or who are systemically unwell (oral antibiotics may be indicated)
• If cellulitis spreads outside the ear canal (oral antibiotics are indicated)
• With known perforation of the tympanic  membrane – acute or chronic
• With a grommet
• If the ear canal is occluded
• In extreme pain or discomfort – refer to the GP/out-of-hours service
• With considerable discharge (otorrhoea) or extensive swelling of the auditory canal. Microsuction or ear wick insertion may be required
• Who have had a previous episode in the last three months
• Who have been treated with antibiotics for the current episode of otitis externa but treatment has not been effective in managing their symptoms
• Who are pregnant or breastfeeding
• With chronic otitis externa – inflammation or symptoms that have lasted for more than three months.

Red flags

Signs of sepsis or malignant otitis. These are rare and the patient is likely to be so unwell that they would not present at the pharmacy. Symptoms include unremitting and disproportionate ear pain, headache, purulent otorrhoea, fever or malaise, vertigo and profound conductive hearing loss.