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Navigating Otitis Externa: Bacterial vs Fungal

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Otitis externa, commonly known as “swimmer’s ear,” is an inflammatory condition affecting the external ear canal. It can be caused by bacteria, fungi, or a combination of both. As healthcare professionals in the UK, understanding the nuances between bacterial and fungal otitis externa is crucial for accurate diagnosis and effective management.

Bacterial Otitis Externa


Common Pathogens: Bacterial otitis externa is primarily caused by Pseudomonas aeruginosa and Staphylococcus aureus. Polymicrobial infections are also frequent.

Risk Factors: Swimming, excessive moisture, trauma, and the use of hearing aids or earplugs can predispose individuals to bacterial otitis externa.

Clinical Presentation

Symptoms: Patients typically complain of severe ear pain, especially when pulling the pinna or pressing the tragus. The ear canal may appear narrow, oedematous, and filled with malodorous creamy or dry pus.

Physical Examination: Examination reveals erythema, oedema, and debris within the ear canal.


Aural Toilet: Thorough cleaning of the ear canal is essential. Remove debris and pus to facilitate medication penetration.

 Topical Antibiotics: Commonly used antibiotic ear drops include Locacorten® Vioform, Otocomb®, or Kenacomb®. These combinations provide both antimicrobial and anti-inflammatory effects.

Fungal Otitis Externa


Common Pathogens: Fungal otitis externa is less common but often caused by Aspergillus (80-90%) or Candida.

Risk Factors: Prolonged moisture exposure, immunosuppression, and prior antibiotic use can predispose individuals to fungal infections.

Clinical Presentation

Symptoms: Pruritus (itchiness) is more prominent than pain. Patients may describe a sensation of fullness or discomfort.

Physical Examination: The ear canal may contain thick, “wet newspaper”-like debris (hyphae) and “salt and pepper” specks (spores).


Aural Toilet: Similar to bacterial otitis externa, thorough cleaning is crucial.

Antifungal Agents: Topical antifungal ear drops or ointments are used. Examples include Otocomb Otic® or Kenacomb Otic®.

Differential Diagnosis

Malignant Otitis Externa: A rare but serious condition seen in immunocompromised patients, often caused by Pseudomonas aeruginosa.

Allergic Otitis Externa: Hypersensitivity reactions to topical medications or ear drops.

 When to Refer

Red Flags: Cranial nerve signs, severe pain, immunodeficiency, or diabetes warrant prompt referral to an ear, nose, and throat (ENT) specialist.


Prompt recognition of complications is crucial.

Common complications include:

Cellulitis, Perichondritis, Malignant otitis externa, Abscess formation.

 Chronic Cases: If symptoms persist beyond 4 weeks, consider referral for further evaluation.


As UK healthcare professionals, accurate diagnosis and appropriate management of otitis externa are essential. Collaborate with ENT specialists when needed and educate patients on preventive measures to avoid recurrence. By distinguishing between bacterial and fungal aetiologies, we can provide optimal care for our patients suffering from this common ear condition.

Are you a primary care health care provider that wants to enhance your minor illness skills? Practitioner Development UK offer the following courses that may work for you. 

Minor Ailments Essentials (Online): Designed for nurse practitioners, practice nurses, and other allied health professionals. Accredited by the RCN Centre for Professional Accreditation.

Minor Ailments: Ear and Eye Conditions (Online): Get up to speed with evidence-based assessment and management of common ear and eye conditions. Ideal for practice nurses, community nurses, and registered nurses. Course covers focused history-taking and safe practice.


Dickson, E. (2018). Otitis Externa: Review and Clinical Update.SAGE Journals. Retrieved from Otitis Externa: Review and Clinical Update

Medina-Blasini, Y., & Sharman, T. (2023). Otitis Externa - StatPearls.In StatPearls. Retrieved from Otitis Externa - StatPearls