Otitis externa can be a difficult condition to manage well in General Practice and the art of this lies in knowing when to refer the patient. The obvious (although surprisingly undervalued) rule is that if the ear is filled with discharge, drops will not get into the canal. A tissue rolled to a point and blunted on the end may be a useful tool to remove discharge (and at this point, you hope your patient is co-operative). Afterwards, a gauze wick saturated in the medicated ear drop may be inserted and replaced daily. If the ear cannot be sufficiently cleared of pus and debris by the doctor, the patient will need to be referred. If this does not happen, the infection may appear to come under control, but the bacteria or fungus will reactivate from the remaining matter in the ear canal at some stage after the ear drops have been finished. This is even more likely in swimmers and children, as it is harder for them to keep the ears dry (a necessity during treatment). It is not wise to try to syringe an ear to clear infected debris, as it may worsen the infection or rupture the eardrum.
If there is significant, painful, canal swelling, a swab for culture is strongly advised. An oral antibiotic will be needed and an urgent ear nose and throat appointment should be arranged, as is it even more difficult to remove residual debris and discharge. Pseudomonas needs to be considered if the patient has had a fresh water exposure, especially warm water (spas, tropical pools). Although ciprofloxacin drops are safe for use in children, pseudomonas is only responsive orally to ciprofloxacin and norfloxacin; these should be avoided in patients who are not through puberty (due to potential abnormalities in immature cartilage and joints). Finally, consider precipitating environmental and health problems contributing to otitis externa and its recurrence (e.g. diabetes, eczema, cotton buds).