Introduction Acute otitis externa (AOE) represents a common presentation to the Emergency Department. Clinical guidelines exist for the management of AOE. Aims The primary aim of this study was to examine the presentation and management of AOE in a rural environment. The secondary objective was to compare management against established guidelines. Methods A retrospective cohort study was performed on all patients presenting to Dubbo Base Hospital Emergency Department with a diagnosis of AOE over a two-year period from 2022 to 2023. Data on presentation and management were collected and compared to the Therapeutic Guidelines. Results There were 208 patients included across the two-year period. The median age was 24 years old (IQR 11-41) with an even distribution of males (n=104, 50%) and females (n=104, 50%). Unilateral symptoms (n=191, 92%) were most common with a median duration of 2 days (IQR 1-4 days). Twenty-five (12%) had ear swabs taken, with the most common organism being pseudomonas aeruginosa (n=16, 64%), followed by staphylococcus aureus (n=3, 12%). Sixty-four patients (31%) were advised to keep their ears dry during treatment and 10 patients (4.8%) were not prescribed antibiotic ear drops. The most common topical antibiotics drops were dexamesthasone + framycetin sulfate + gramicidin (n=99, 50%) and ciprofloxacin/hydrocortisone (n=62, 31%). Forty-four patients (21%) were prescribed ototoxic topical drops without visualisation of the tympanic membrane to rule out perforation. Eighty-five (41%) of patients were prescribed oral antibiotics. Of those prescribed oral antibiotics, 59 (69%) did not require systemic antibiotics and 75 (88%) had an inappropriate choice of antibiotic. Conclusion There were a large portion of patients who were prescribed ototoxic ear drops without tympanic membrane visualisation and prescribed inappropriate or insufficient systemic antibiotics.