What criteria should I use to decide whether to refer a patient with chronic otitis externa to an ENT specialist?

Refer a patient with chronic otitis externa to an ear, nose, and throat (ENT) specialist if any of the following criteria are met:

• Persistent pain affecting the ear lasting 1 week or more that has not responded to first-line treatment.
• History of ear discharge (other than wax) that has not resolved, has not responded to prescribed treatment, or recurs.
• Partial or complete obstruction of the external auditory canal preventing full examination of the eardrum or taking an aural impression.
• Abnormal appearance of the outer ear or eardrum, such as inflammation, polyp formation, perforated eardrum, abnormal bony or skin growths, swelling of the outer ear, or blood in the ear canal.
• Hearing loss associated with the chronic otitis externa that is unexplained by acute external or middle ear causes.
• Immunocompromised adults with otalgia and otorrhoea not responding to treatment within 72 hours.

These criteria help identify patients who require specialist assessment and management beyond primary care.