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External Otitis

 

External Otitis At A Glance

What is  acute external otitis?

External otitis or is an infection of the skin covering the outer ear canal. Acute external otitis is commonly a bacterial infection caused by streptococcus, staphylococcus, or pseudomonas types of bacteria. Swimmer’s ear is a variant of otitis externa usually caused by excessive water exposure. When water pools in the ear canal (frequently trapped by wax), the skin will become soggy and serve as  an inviting medium for bacteria and fungi

The first sign of infection is that the ear will feel full and it may itch. Next the ear canal will swell and ear drainage will follow. At this stage the ear will be very painful, especially with movement of the outside portion of the ear. The ear canal can swell shut and the side of the face can become swollen. Next, the glands of the neck may enlarge, and it can become painful to open the mouth.

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What is chronic external otitis?

Chronic external otitis can be caused by a bacterial infection, a skin condition (eczema or seborrhea), fungus (Aspergillosis), chronic irritation (hearing aids, Q-tips), allergy, chronic drainage from middle ear disease, tumors (rare), or it may simply follow from a nervous habit of frequently scratching the ear. In most patients, more than one factor may be involved. For example, a patient with eczema may subsequently develop black ear drainage. This would be suggestive of an accompanying fungus. The standard treatments and preventative measures, as noted below, are often all that is needed to treat even a chronic otitis externa. However, in diabetic or immune suppressed individuals, chronic external otitis can become a serious disease (malignant external otitis). Malignant external otitis is a misnomer because it is not a tumor or a cancer, but rather an aggressive bacterial (pseudomonas) infection of the base of the skull.

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How do you treat external otitis?

Regardless of the cause, moisture and irritation will prolong the course of the problem. For this reason, the ear should be kept dry. While showering or swimming use an ear plug (one that is designed to keep water out) or use cotton with Vaseline on the outside.

Scratching the inside of the ear or using Q-tips should be avoided. This will only aggravate the irritated skin, and in most situations will make the condition worse. In fact, scratching the inside of the ear will just make the ear itch more, and any medications prescribed will be ineffective. A hearing aid should be left out as much as possible until swelling and discharge stops.

The most common treatment consists of antibiotic ear drops  with or without an oral antibiotic. These should be used as directed. In some situations, a "wick" will need to be placed in the ear canal to stent it open and serve as a conduit for the ear drops. Periodic, and sometimes frequent, suctioning of the ear canal helps to keep it open, remove debris, and decrease bacterial counts.

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How can external otitis be prevented?

  1. Decrease exposure to water. If you are prone to infections it is advisable that you use an ear plug when you bathe or swim. Alcohol drops (Swim Ear) used in the ear after water exposure followed by drying the ear with a hair dryer held at arms length will often help keep the ear free of moisture.
     

  2. Do not insert instruments, scratch, or use Q-tips in the ears.

     

  3. Try to keep the ear free of wax. This may require maintenance type visits to the doctor to have your ears cleaned, or if your ear will tolerate it, use some of the over-the-counter wax removers.
     

  4. If you already have an ear infection, or if you have a hole in your eardrum, or if you have had ear surgery or ear tubes, first consult your doctor prior to swimming and before you use any type of ear drop.
     

  5. A preventative ear drop solution can be cheaply and easily made by mixing equal parts of rubbing alcohol and white vinegar (50:50 mixture). This solution will increase the rate of evaporation of water in the ear canal and has antibacterial properties.
     

  6. Mineral oil ear drops can be used to protect the ear from water when a dry crusty skin condition exists.

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Why do ears itch?

Itchy ears can drive a person crazy. It can be the first sign of an infection, but if the problem is chronic, it is more likely caused by a chronic dermatitis of the ear canal. Seborrheic dermatitis and eczema can both affect the ear canal. There is really no cure for this problem, but it can be made tolerable with the use of steroid drops and creams. People with these problems are more prone to acute infectious exacerbations. Use of ear plugs, alcohol drops, and non-instrumentation of the ear is the best prevention for infection. Other allergy type treatments may also help itchy ears.

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What if I get a foreign object or insect in my ear?

Foreign objects are frequently placed in the ear by young children or occur accidentally while trying to clean or scratch the ear. Frequently there is an accompanying external ear infection. Removal of any object from the ear can be very difficult, and should only be attempted by a physician skilled in the techniques of safe removal. Usually this can be done in the office, but sometimes general anesthesia must be used in cases where the object is lodged too deeply in the ear or if the patient is uncooperative. It is important to remember that the most common reason an ear is injured from a foreign object is because of inadvertent damage occurring during removal of the object.

Insects or bugs may also become trapped in the ear. Small gnats may become caught in the wax and cannot fly out. They can often be washed out with warm water. Larger insects or bugs may not be able to turn around in the narrow canal. If the insect or bug is still alive, first kill it by filling the ear with mineral oil. This will suffocate the insect, then see your doctor to have it removed.

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External Otitis At A Glance
  • External otitis, or swimmer’s ear, is an infection of the outer ear canal skin and can occur in acute and chronic forms.

  • Excessive water exposure and frequent instrumentation (usually Q-tips) of the ear canal are important causative factors.

  • Itchy ears, a feeling of fullness, swelling, drainage, and pain are early symptoms.

  • Antibiotic ear drops and avoidance of water are frequently necessary for treatment.

  • Proper ear care can avoid most infections

1. Mild OE

Canal skin may be red with exudate; you may perceive narrowing of the canal lumen.

 

2. Moderate OE

The canal lumen is narrowed, and can be swollen shut. Skin is erythematous. Exudate may be present.

 

3. Complicated OE

The pinna/periauricular soft tissues are erythematous and swollen as well.

 

4. Chronic OE

The skin of the canal/pinna is thickened, scaly, and may be erythematous.

 

Diagnostic Pearl: How to Differentiate Otitis Media from Otitis Externa

Pulling on the pinna (ie: to examine with an otoscope) is extremely painful in otitis externa, but is usually tolerated in patients with otitis media.

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Necrotizing (Malignant or Diabetic) Otitis Externa

 

Key Points in the History:

This is typically associated with elderly diabetics or other immunocompromised patients. Patients complain of otalgia and otorrhea persisting more than a month, unresponsive to medical therapy.

Key Physical Signs:

Look for granulation tissue on the floor of the external auditory canal in the presence of purulent otorrhea. In advanced cases, you'll see cranial neuropathy, most commonly CN VII, X, or XI.

Key Diagnostic Tests:

CT of temporal bones: shows mastoid clouding, bony destruction

Gallium-67 scan: shows an acute infective focus: will revert to normal with resolution of infection

Technetium-99 scan: shows osteoblastic activity; will revert to normal many months after clinical resolution

MRI: monitors cerebral, vascular involvement

Key Therapeutic Options:

As in moderate otitis externa: frequent debridements, topical antipseudomonal antibiotics, combined with IV antipseudomonals: Ciprofloxacin, Gentamicin, Tobramycin, etc. Treatment continues for 6 weeks to 6 months (can switch to oral antibiotics from IV). Diabetic management should be optimized if applicable. Surgical debridement of necrotic bone is reserved for non-responders.