Otitis Exter na

Jennifer Wipperman, MD, MPH

KEYWORDS
Acute otitis externa Chronic otitis externa Antibiotics Topical steroids

KEY POINTS

Acute otitis externa most often is infectious in origin, and can be easily treated with a
com-bination of topical antibiotic and steroid preparations.
Systemic antibiotics are rarely needed for acute otitis externa.
Chronic otitis externa can be more difficult to treat, but if an underlying cause can be
iden-tified this condition can often be successfully managed.
In both acute and chronic otitis externa, prevention is fundamental. If patients are able to
avoid precipitating factors, future episodes can often be averted.

Otitis externa is a common problem seen in the primary care office, and most cases are
managed by primary care providers.1 Otitis externa is an inflammatory condition of the
external ear canal, with or without infection. Inflammation may be localized to the ear
canal, or include portions of the outer ear, such as the pinna or tragus. Acute otitis externa
(AOE) is defined as lasting less than 6 weeks, and chronic otitis externa (COE) as lasting
3 months or longer. AOE, also known as swimmer’s ear, is usually an infectious condition,
whereas COE more often has a noninfectious, allergic cause.

ACUTE OTITIS EXTERNA

Epidemiology
The overwhelming majority (>95%) of otitis externa cases are acute. 2 AOE occurs
most often in the summer and in warmer, humid climates. Each year, 1 to 2.5 in 100
people are affected.1,2 Peak incidence arises among children of age 7 to 12 years,
and is 5 times more common in regular swimmers. 3
Risk Factors
In addition to living in warmer, humid climates and swimming, other risk factors relate
to increased moisture in the ear canal, loss of protective cerumen, and trauma to the
ear canal.4 Cerumen impaction can cause water retention in the ear canal and may

Depertment of Family and Community Medicine, University of Kansas School of Medicine –

Wichita, 1010 North Kansas, Wichita, KS 67214, USA E-mail address:
[email protected]

Prim Care Clin Office Pract 41 (2014) 1–9

http://dx.doi.org/10.1016/j.pop.2013.10.001 primarycare.theclinics.com 0095-4543/14/$ – see front
matter 2014 Elsevier Inc. All rights reserved.
2 Wipperman

predispose to AOE. On the other hand, removal of cerumen by excessive cleaning

leads to a loss of protective waxy barrier and breakdown of the epithelial lining.
Trauma to the ear canal may also occur from use of a hearing aid or ear plug. AOE
is more common among those with chronic dermatologic conditions, such as psoria-
sis or atopic dermatitis, which causes debris and skin breakdown in the ear canal. 5
Finally, those who are immunocompromised, including patients with diabetes
mellitus, may have more severe and resistant cases of AOE.2
Pathophysiology
The external auditory canal is about 25 mm long and curves in an S-shape toward the
tympanic membrane.4 The outer one-third of the canal base is cartilaginous whereas the
inner two-thirds is bony. Hair follicles and cerumen-producing glands cover the outer one-
third of the canal. Cerumen has several protective functions in the ear canal. First, it
provides a waxy barrier that protects the epithelium from breakdown caused
by excessive moisture exposure. Second, cerumen has a slightly acidic pH and lyso-
zymal activity that inhibits bacterial and fungal growth. 6 Disturbance in the normal
acidic environment, lack of cerumen, and trauma to the epithelial lining can lead to
bacterial or fungal infection of the ear canal, causing an inflammatory response.
More than 98% of infectious AOE is bacterial. 3 The most likely pathogens include
Pseudomonas aeruginosa and Staphylococcus spp, and AOE is often a polymicrobial
infection. Less often, gram-negative bacteria may be involved. Rarely, AOE may
result from a fungal (Candida or Aspergillus) infection.7
Clinical Presentation
Patients with AOE present with the rapid onset of ear pain, fullness, and otorrhea.
Pain that is worse with traction on the pinna or palpation of the tragus is the hallmark
of AOE. In the initial stages, patients may experience mild discomfort and ear
pruritus. On examination, the ear canal may be erythematous and slightly
edematous, with min-imal discharge. Often the severity of pain experienced by the
patient is dispropor-tionate to physical examination findings. As the condition
progresses, the canal may become extremely edematous and nearly obstructed from
additional otorrhea and debris. Inflammation may spread to the tympanic membrane,
causing myringitis. A sensation of ear fullness may occur, as well as hearing loss if
obstruction is severe. Regional lymphadenitis and surrounding cellulitis of the pinna
may be present. Of importance, systemic symptoms such as fever and malaise
suggest extension beyond the ear canal.

Diagnosis
AOE is a clinical diagnosis, the criteria of which are listed in Box 1. Diagnosis requires
a history of rapid onset (within the last 48 hours) occurring in the last 3 weeks with
signs and symptoms of ear canal inflammation. 2 Symptoms include otalgia, itching,
or fullness, with or without hearing loss. Signs include tenderness of the outer ear or
diffuse ear-canal edema or erythema with or without otorrhea, regional
lymphadenop-athy, tympanic membrane erythema, or surrounding cellulitis. Several
other conditions can mimic AOE, and should be differentiated (Table 1).
In uncomplicated cases, obtaining cultures of otorrhea is not necessary. However,
bacterial and fungal cultures may be helpful in resistant or recurrent cases in patients
with a history of frequent topical antibiotic use or the immunocompromised. If malig-
nant (necrotizing) otitis externa is suspected, cultures should always be obtained.
Pneumatic otoscopy and tympanometry are useful in differentiating AOE from acute
otitis media (AOM). This distinction is important because otitis media would require
 Otitis Externa 3

Box 1
Diagnostic criteria for acute otitis externa

1. Rapid onset (generally within 48 hours) in the past 3 weeks, AND

2. Symptoms of ear canal inflammation that include:
Otalgia (often severe), itching, or fullness
WITH OR WITHOUT hearing loss or jaw pain, AND
3. Signs of ear canal inflammation that include:
Tenderness of the tragus, pinna, or both
OR diffuse ear canal edema, erythema, or both
WITH OR WITHOUT otorrhea, regional lymphadenitis, tympanic membrane erythema, or
cellulitis of the pinna and adjacent skin

Data from Rosenfeld RM, Brown L, Cannon CR, et al. Clinical practice guideline: acute otitis ex-
terna. Otolaryngol Head Neck Surg 2006;134(Suppl 4):S4–23.

Table 1
Differential diagnosis of acute otitis externa

Condition Clinical Characteristics

Carcinoma of the ear canal May be indistinguishable from otitis externa. Consider if
abnormal tissue growth in ear canal, or patients with mild
pain, bloody otorrhea, and lack of response to treatment
of otitis externa
Chronic suppurative otitis Develops after tympanic membrane rupture in acute otitis
media media. Chronic drainage leads to otalgia, otorrhea, and,
possibly, eczematous changes
Contact dermatitis Often develops after exposure to topical agents such as
neomycin, anesthetics, or commercial products. Itching
usually present. May see maculopapular rash on conchal
bowel and edematous ear canal
Eczema or psoriasis Patients with history of disorder and/or typical rash present
elsewhere on the body. May have ear canal pruritus,
hyperkeratosis, and lichenification
Furunculosis Infection of hair follicle in ear canal manifested by a tender,
erythematous papule or pustule
Herpes zoster oticus Causes vesicles on external ear canal, posterior auricle, and,
possibly, tympanic membrane. Patients often have severe
otalgia and facial nerve palsy
Malignant otitis externa Consider in patients with findings of severe otitis externa
unresponsive to treatment, granulation tissue in ear canal,
and systemic signs such as temperature >38 C
Otomycosis Patients often experience itching more than otalgia. Fluffy,
cotton-like debris may be noted in the ear canal, possibly
with hyphae and otorrhea
Seborrheic dermatitis May see typical seborrhea on face, hairline, and scalp. Ear
canal often with minimal cerumen and is flaky, shiny, dry,
and erythematous
4 Wipperman

oral antibiotics of an appropriate regimen. In cases of otitis externa, pneumatic

otoscopy will show normal motion of tympanic membrane, and tympanometry will
show a normal peaked tracing. On the other hand, in AOM there will be negligible
motion of tympanic membrane with pneumatic otoscopy and a flat tracing on tympan-
ometry. If the tympanic membrane is obstructed from canal edema and discharge,
tympanometry can be used to determine whether it is intact. In the presence of AOE
without AOM, tympanometry will show a normal tracing if the tympanic mem-brane is
intact.

Treatment
The mainstays of treatment for AOE include pain control, treatment of infection, and
avoiding precipitating factors. These goals are most often accomplished with aural
toilet, a topical antibiotic and topical steroid, and over-the-counter oral pain medica-
tion if needed. Oral antibiotics are rarely indicated.
Topical antibiotics are effective for most cases. Most often, an aminoglycoside or
fluoroquinolone antibiotic is used, as they include coverage of Pseudomonas and
Staphylococcus spp. An aminoglycoside preparation, as found in Cortisporin Otic, should
be avoided if the tympanic membrane is perforated or if the patient has a his-tory of
contact sensitivity to neomycin. Up to 15% of the population has contact sensi-
tivity to neomycin, which increases to 30% among those with chronic or eczematous
otitis externa.8,9 Aminoglycosides are ototoxic, and can lead to hearing loss and ver-tigo if
they reach the inner ear.10 Both aminoglycoside and fluoroquinolone antibiotics have a
70% to 90% clinical response rate.11 Because topical acetic acid preparations (VoSol)
have anti-infective activity and drying action, they exhibit clinical cure rates
similar to those of topical antibiotics for AOE.11 However, acetic acid preparations
may be less effective if needed for a longer than 1 week. 12
A 2010 Cochrane review found no difference in efficacy between classes of antibi-
otics.11 Therefore, choice of antibiotic should be based on factors such as risk of
ototoxicity, contact sensitivity, availability, cost, dosing schedules, and patient compli-ance
(Table 2). Because topical antibiotics reach a high concentration in the ear canal,
even bacterial strains considered resistant to systemic antibiotics (ie, methicillin-
resistant Staphylococcus aureus) are susceptible to topical antibiotic preparations. 2 The
addition of a topical steroid results in reduced canal edema and otorrhea, and has-
tens pain relief.11,13 Many topical antibiotic preparations include a steroid component. In
general, patients should be treated for 7 to 10 days. 2 Practically, patients may be advised
to use drops for 1 week. If symptoms are not resolved they may continue to use drops
until a few days after symptoms resolve, up to 1 additional week. If symptoms still persist
at day 14, this should be considered a treatment failure.
Proper use of topical antibiotics is important, and misunderstanding of technique
can lead to treatment failure. For this reason, placement of drops should be taught
in the office. Up to 40% of patients do not self-administer drops correctly.14 Having
someone else administer topical preparations is therefore usually more effective. Pa-
tients should lie on their side with the affected ear up. Drops should be placed to run
along the side of the ear canal until it is filled, gently moving the pinna to and fro to
elim-inate air trapping and ensure filling. Patients should remain in this position for at
least 3 to 5 minutes.
For topical antibiotics to be effective, they must contact the epithelial lining. There-
fore, in patients with a significant amount of debris or otorrhea, aural toilet may be
necessary. In general, debris can be cleared using gentle suction, irrigation, or dry
mopping with cotton. Impacted cerumen and foreign bodies should be removed.
Gentle irrigation should be used only if the tympanic membrane is intact, and should
 Otitis Externa 5

Table 2
Common topical antimicrobial preparations for acute otitis externa
Brand Cost of Generic
Component Name (Brand) Dosage Comments
Acetic acid 2% VoSol $30 for 15 mL 3–5 drops Avoid if tympanic
($36 for 15 mL) every 4–6 h membrane
ruptured. May
cause local
irritation
Acetic acid 2%/ VoSol HC $50 for 10 mL 3–5 drops As above
hydrocortisone ($50 for 10 mL) every 4–6 h
Neomycin/ Cortisporin $18 for 10 mL 3–4 drops —
polymyxin B/ ($100 for 10 mL) every 6–8 h
hydrocortisone
Ciprofloxacin/ Cipro HC Not available 3–4 drops 7-Day course
hydrocortisone ($190 for 10 mL) every 12 h adequate
Ciprofloxacin/ Ciprodex Not available 3–4 drops As above
dexamethasone ($160 for 7.5 mL) every 12 h
Ofloxacin Floxin Otic $20 for 5 mL 10 drops once 7-Day course
($80 for 5 mL) daily adequate

Data from GoodRX. Available at: www.goodrx.com. Accessed November 20, 2013.

be avoided in patients with poorly controlled diabetes mellitus or the immunocompro-

mised. Irrigation has been associated with malignant otitis externa. 15
Ear wicks may ensure adequate antibiotic delivery in patients with marked edema.
Wicks are made of compressed cellulose material, and expand when exposed to
moisture. This approach facilitates drug delivery and reduces edema. 16 Once a wick
is placed, it should be moistened with saline. Edema generally improves within the
first few days, after which the wick will fall out spontaneously, or it may be removed
by the clinician at a follow-up visit.
For pain control, most patients may use oral over-the-counter medications such as
acetaminophen or ibuprofen.2 As already noted, the addition of a topical steroid has-
tens pain relief by a median of 1 day compared with topical antibiotics alone. If pain
is severe, narcotic pain medications may be necessary. Topical benzocaine prepara-
tions are generally best avoided in AOE. Although benzocaine’s anesthetic action
pro-vides excellent pain relief, it can mask progression of disease. Furthermore, the
additional drops can limit penetration of topical antibiotics. Some patients may also
develop contact dermatitis from topical benzocaine. 17
Even though systemic antibiotics are rarely needed in AOE, they continue to be pre-
scribed to one-third of patients with AOE.18 Frequently the chosen antibiotic is not
effective against Pseudomonas. Moreover, systemic antibiotics are associated with
increased bacterial resistance, side effects, and increased cost. Systemic antibiotics are
indicated in patients with surrounding cellulitis of the external ear and beyond, un-
controlled diabetes, the immunocompromised, those with a history of radiation to the
head, and those in whom canal edema limits penetration of topical antibiotics. 2
Finally, patients with AOE should avoid precipitating factors. In general, swimming
should be avoided until the infection is resolved, although recreational swimming
may be allowed as long as patients do not submerge their head. Competitive
swimmers should avoid swimming for 2 to 3 days, or until the pain resolves if they
use well-fitting ear plugs. Use of hearing aids and ear plugs should be avoided until
symptoms resolve.
6 Wipperman

Monitoring

Most patients with AOE will experience significant improvement within 24 hours. 16 If
patients do not improve within 48 to 72 hours, they should be reevaluated. Clinical
failure may be due to nonadherence, inadequate drug delivery, canal obstruction, or
misdiagnosis. Although most patients can be treated by their primary care provider,
referral is indicated in cases of suspected malignant otitis externa, lack of improve-
ment, or an inability to remove obstructing debris or a foreign body.

Prevention
Patients with AOE should prevent future episodes by limiting predisposing factors.
Moisture retention in the ear canal should be minimized, and a healthy skin barrier
maintained. Excessive moisture can be avoided in several situations. Swimmers may
use well-fitting ear plugs while swimming to prevent water retention in the ear canal.
After water exposure, the head should be tilted and the ear gently pulled to empty
any residual water. A hair dryer on the lowest heat setting may be used to help dry
the ear. In addition, acidifying drops, such as acetic acid 2% (VoSol otic so-lution)
may be placed in the ear after water exposure to dry the ear canal.
Sources of ear trauma should also be avoided. Patients should be instructed to
stop frequent ear cleaning, especially with cotton-tipped applicators. Hearing aids
should be examined to ensure that they fit well. Underlying dermatologic conditions
should be adequately treated.

Complications
In AOE, infection may spread from the ear canal itself to surrounding structures,
leading to auricular or facial cellulitis, perichondritis, or chondritis. 4 Ongoing chronic
infection may result in canal stenosis and hearing loss. 19
Malignant (necrotizing) otitis externa is a severe life-threatening complication of
AOE.20 It may occur in untreated cases where infection extends to the temporal
bone, causing osteomyelitis and systemic toxicity. Pseudomonas is most often impli-
cated. Malignant otitis externa is most common among adult patients, including
the elderly, those with diabetes mellitus, and the immunocompromised. 15 Nearly
90% to 100% of patients with malignant otitis externa have diabetes mellitus. 20
Further complications include meningitis, dural sinus thrombosis, cranial abscess,
and cranial nerve palsies. Facial nerve paralysis may be seen early during infection.
Malignant otitis externa should be suspected in patients with signs of systemic toxicity,
such as fever, or failure to improve with topical antibiotics. In addition to symptoms of
severe AOE, patients may also complain of headache, temporal mandib-ular joint pain,
and trismus. On examination, in addition to severe canal edema, ery-thema, and otorrhea,
granulation tissue is often present on the floor of the canal, especially at the bony-
cartilaginous junction. Diagnosis is confirmed by imaging with computed tomography or
magnetic resonance imaging. Patients will often have an elevated sedimentation rate, and
cultures of otorrhea should always be ob-tained. Treatment requires initial empiric
intravenous antibiotics that cover Pseudo-monas. In severe or resistant cases, surgical
debridement may be necessary.

CHRONIC OTITIS EXTERNA

In contrast to AOE, chronic otitis externa (COE) is more often attributed to allergic or
autoimmune causes than infectious etiology. Less than 5% of otitis externa is
chronic.2 However, COE is often a disturbing and sometimes disabling condition for
the 3% to 5% of the population affected by it.21 COE represents a common pathway
 Otitis Externa 7

for several different disease states. It may be caused by allergic contact dermatitis,
autoimmune disorders, chronic dermatologic conditions such as psoriasis, or chronic
infection from fungi or bacteria.4,19
Clinical Presentation
Patients with COE present with itching of the ear, clear or mucoid otorrhea, and aural
fullness. Ear pain or discomfort and hearing loss may be present if the ear canal is
acutely inflamed and swollen. Many patients experience a waxing and waning course
over years with intermittent exacerbations.2 In at least half of patients, both ears are
affected. At times patients may also experience AOE. 19
Physical Examination
Physical examination findings in COE often vary depending on the cause. For
example, patients with contact dermatitis may exhibit a maculopapular rash with
excoriations on the skin of the conchal bowel and ear canal. Patients with chronic
dermatologic conditions such as psoriasis and atopic dermatitis may show eczema-
tous changes, hyperkeratosis, and lichenification of the ear canal epithelium. The ear
canal may be weepy, erythematous, and tender as well. Seborrheic dermatitis may
result in a lack of cerumen and dry, flaky, erythematous skin in the canal, with or
without clear otorrhea. COE has also resulted from chronic otitis media with tym-
panic membrane perforation. Purulent middle-ear drainage can enter the ear canal
and lead to an eczematous dermatitis. Finally, the ear canal in patients with fungal
infection (otomycosis) may show fluffy, cotton-like debris. Sprouting hyphae or dots
of black debris and thick otorrhea of various colors may also be observed.

Diagnosis
Diagnosis of COE is made clinically in patients with typical signs and symptoms of at least
3 months’ duration.19 Culture for bacteria and fungi is often prudent if chronic infection is
suspected. Patients with possible contact dermatitis should be thoroughly questioned
about the use of various agents such as neomycin, shampoos, detergents, hairsprays,
and hearing-aid molds. Skin-patch testing in cases of contact dermatitis may be useful to
elucidate the cause.17 Chronic dermatologic disorders such as pso-riasis should be
suspected when a typical exanthem is visualized elsewhere on the skin. Finally, patients
may have COE resulting from systemic autoimmune disorders already identified, such as
Wegener granulomatosis and sarcoidosis.22,23
Treatment
Treatment of COE is aimed at identifying the underlying cause and managing
accord-ingly. All patients should have aural toilet if needed, and be given preventive
precau-tions as for AOE. For patients with contact dermatitis, avoidance of any
potential irritants is paramount. Topical steroid therapy with medium-potency
(triamcinolone 0.1% cream) and high-potency (desoximetasone 0.05% cream)
agents is often effec-tive for patients with contact dermatitis or chronic dermatologic
conditions.17,19 Cream preparations are preferred, and a small amount can be
applied to the skin at the meatus twice daily. At times, higher-potency topical steroids
or a short course of oral steroids may be necessary. Topical tacrolimus has also
been used with suc-cess in noninfectious COE.24
Patients with chronic bacterial infection should be treated with topical antibiotics,
as for AOE. In cases of fungal otitis externa, antifungal creams such as clotrimazole
1% may be used.25 Acidifying topical agents are also beneficial. Gentian violet is an
antifungal and drying agent that can be applied in the office.19 It is painted on the
8 Wipperman

ear canal using a home-made Q-tip (ie, a toothpick wrapped in cotton). Recalcitrant
or severe cases, such as those involving Aspergillus, may require oral itraconazole.4

Complications
Patients with COE are predisposed to AOE because of the breakdown in epithelial
lining resulting from excessive moisture, trauma, itching, and accumulation of debris.
Fungal infection may result in perforation of tympanic membrane. 26 A major complica-tion
of COE is fibrosis of the medial canal. 27 After long-standing inflammation, a thick, fibrous
scar can form at the medial end of the ear canal. The tympanic membrane may appear to
be oriented laterally and have fibrotic changes, with absence of typical land-
marks. Eventually a fibrotic plug may become obstructive, resulting in a blind-ending
canal associated with conductive hearing loss.19

SUMMARY

Otitis externa is a common condition seen by primary care clinicians, who should be
familiar with its diagnosis and management. AOE most often is infectious in origin,
and can be easily treated with a combination of topical antibiotic and steroid prepara-
tions. Systemic antibiotics are rarely needed. COE can be more difficult to treat, but if
an underlying cause can be identified this condition can often be successfully
managed. In both AOE and COE, prevention is fundamental. If patients are able to
avoid precipitating factors, future episodes can often be averted.

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 Otitis Externa 9

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