Basics
Description
- Diffuse inflammation of external auditory canal with or without infection
- Also known as "swimmer 's ear "
- May be categorized as acute, chronic, or malignant
- Acute: rapid onset, usually bacterial
- Chronic: lasting longer than 4 weeks or occurring 4 or more times in 1 year, usually due to nonbacterial causes such as atopic or allergic contact dermatitis from contact with metal, plastic, or chemicals
- Malignant or necrotizing: extension of infection to osteomyelitis of the base of the skull; more common in immunocompromised patients (e.g., HIV, diabetes)
Epidemiology
- Peaks in children age 5 " 14 years
- Uncommon in children younger than age 2 years
- Peaks in summer months in temperate climates; occurs year-round in warm/humid climates
Incidence
- Annual incidence is 8.1/1,000 in the general population.
Prevalence
- Affects 3 " 5% of the population
Risk Factors
- Prolonged exposure to water (e.g., frequent swimming, shampooing, long showers, excessive sweating) leading to impaired natural defense mechanisms in external ear
- Microfissures from trauma
- Debris from dermatologic conditions (e.g., atopic or seborrheic dermatitis)
- Use of external devices (e.g., hearing aids or ear plugs)
- Obstruction of ear canal (e.g., by impacted cerumen, foreign body, sebaceous cyst)
- Chronic otorrhea or purulent otorrhea from otitis media
- Drainage from tympanostomy tubes
- Hairy ear canal
- Anatomic abnormalities
- Stenosis of ear canal
- Exostoses (abnormal bone growth within the ear canal)
- Hx of radiotherapy leading to damaged epithelium, desquamation, and diminished cerumen production
General Prevention
- Elimination of predisposing factors when feasible is the key to prevention.
- Avoid exposure to excessive moisture.
- There are no randomized trials evaluating preventive strategies but you may instruct swimmers to keep their ears as dry as possible by toweling off, tilting the head to assist with drainage, and using a hair dryer to the ear canal on the lowest setting.
- Some experts also recommend the use of ear plugs and caps, although this is controversial because it may lead to cerumen impaction, predisposing to otitis externa (OE).
- Use of a 1:1 alcohol-to-vinegar solution before and after swimming and again before bedtime also may decrease the rate of recurrence.
- Avoid trauma to the ear canal " in particular, avoid cotton-tip swabs or other cleaning devices.
- Manage underlying dermatologic conditions.
Pathophysiology
- The ear canal is lined with apocrine and sebaceous glands that produce cerumen.
- Cerumen serves as a barrier to excessive moisture and may help prevent infection due to lysozyme activity and a slightly acidic pH that helps inhibit the growth of pathogenic bacteria.
- With prolonged exposure to water, cerumen may be washed away and no longer be able to serve this barrier function.
- Too much cerumen can also lead to entrapment of debris and water retention, thus predisposing to infection.
- In certain dermatologic conditions, the integrity of the keratin layer may be affected by excessive desquamation.
- Local trauma to the external canal may also predispose to infection.
Etiology
- In the United States, bacterial agents are implicated in more than 90% of cases and most commonly include Pseudomonas aeruginosa and Staphylococcus aureus.
- May be polymicrobial in up to 30% of cases
- Fungal causes due to Aspergillus niger and Candida species
- Viral infection (in particular, varicella-zoster leading to Ramsay Hunt syndrome) account for a minority of cases.
Diagnosis
History
- Symptoms are rapid in onset (generally within 48 hours) and include otalgia, pruritus, a sense of fullness, drainage, and occasionally impaired hearing.
- 90% of cases are unilateral.
- May have a low-grade fever but temperature over 101 °F (38.3 °C) suggests more serious infection and likely extension beyond the external ear canal.
- Ask about potential predisposing factors including swimming, dermatologic conditions, or trauma.
- Important to know status of immune system (e.g., history of diabetes, HIV infection)
Physical Exam
- Examine external canal, tympanic membrane (TM), regional lymph nodes, and skin for dermatologic conditions.
- Signs of inflammation include tenderness or pain with manipulation of the pinna and with pressure on the tragus, erythema and edema of the external auditory canal, and otorrhea.
- More severe forms of OE may involve regional lymphadenopathy or frank lymphadenitis, cellulitis extending beyond the external canal, and/or perichondritis.
- May be difficult to visualize TM due to edema and debris
- Can clear debris with ear curette or suction
- Avoid lavage until TM is known to be intact.
- Pneumatic otoscopy can assess for TM mobility for diagnosis of otitis media.
- Although rare in children, consider malignant OE if there is necrosis of the skin of the canal, exposed bone or granulation tissue, severe pain, and/or cranial nerve palsy.
- Consider viral infection (Ramsay Hunt syndrome) if there are vesicular lesions with facial paralysis, loss of taste, and decreased lacrimation on the affected side.
Diagnostic Tests & Interpretation
Labs and Diagnostic Procedures
- In uncomplicated OE, testing is generally not indicated.
- Consider bacterial culture of drainage with Gram stain and/or fungal culture in cases of severe illness or treatment failure.
- Consider viral testing if vesicular lesions are present.
- If concerned for malignant OE by history or exam, consider lab work (including erythrocyte sedimentation rate) and imaging (MRI generally preferred over CT scan).
Differential Diagnosis
- Important to rule out life-threatening causes of otalgia and otorrhea
- Clear persistent fluid may occur after traumatic head injury, leading to cerebrospinal fluid otorrhea.
- Purulent otorrhea could be due to acute otitis media associated with mastoiditis, brain abscess, or venous sinus thrombosis.
- With bloody drainage, must consider traumatic perforation of the TM, barotrauma leading to hemotympanum, or a tumor
- Other infections
- Furunculosis in the external auditory canal (also known as localized OE)
- Otomycosis
- Infected sebaceous cyst
- Acute otitis media
- Chronic suppurative otitis media with ruptured TM
- Drainage through tympanostomy tubes
- Miscellaneous
- Foreign body
- Cholesteatoma
- Contact dermatitis (e.g., to metal, plastics)
Treatment
Medication
- For uncomplicated OE, topical antibiotics are the treatment of choice, as they are both effective and well tolerated.
- A 2010 Cochrane review found no difference among topical antibiotic preparations in terms of clinical or microbiologic cure rates. There was also insufficient evidence to suggest that the addition of corticosteroids to topical antibiotic preparations leads to improved outcomes.
- Choice of topical antibiotic therapy should be guided by the following:
- Effectiveness
- Consideration of potential adverse effects
- Patency of the tympanic membrane
- Expected adherence
- Risk of developing drug resistance
- Cost and availability
- Aminoglycoside preparations (e.g., neomycin) should be avoided when the patency of the tympanic membrane cannot be confirmed because of the associated ototoxicity to the middle ear. Note that neomycin can cause an allergic contact dermatitis. Note that neomycin is often combined with polymyxin B for antipseudomonal coverage and hydrocortisone.
- Fluoroquinolone preparations are safe to use in cases of nonintact TM and are dosed once or twice daily, which may increase adherence.
- Tips for medication administration
- Consider warming the ototopical agent to body temperature prior to administration to decrease likelihood of dizziness from caloric stimulation.
- Preferable for parent to administer treatment, even for older children
- Patient should lie with affected ear upward.
- Drops should fill the canal.
- Manipulate the pinna/tragus to help disperse the medication.
- Remain in that position for 3 " 5 minutes.
- Leave canal open to dry (do not insert cotton ball).
- Duration of treatment is usually 7 " 10 days, with expected improvement of symptoms within 3 days and resolution by 6 days.
- For those with symptoms persisting beyond the 7- to 10-day period, treatment should continue until symptoms resolve to a maximum of 14 days, at which point, treatment failure should be considered. At that time, a culture may guide further antimicrobial therapy.
- Oral antibiotics should be considered only in complicated OE (coexisting acute otitis media, lymphadenitis, or facial cellulitis) and in immunocompromised individuals who are at higher risk for developing necrotizing or malignant OE.
Additional Therapies
General Measures
- Pain management
- For mild to moderate pain, acetaminophen or ibuprofen and application of heat or cold packs often will suffice.
- For severe pain, a short course of narcotics may be required because pain may intensify during first 48 hours of treatment.
- There is no data to suggest that benzocaine otic drops are effective for pain management and in fact they may limit the effectiveness of the topical antibiotic by interfering with its contact with the epithelium of the ear canal.
- Clearing aural debris
- In moderate to severe cases of OE when thick drainage obstructs the view of the TM, it may be necessary to clear debris with light suction or manual removal.
- Do not use irrigation until you have confirmed the TM is intact.
- May need to refer to ear, nose, and throat (ENT) physician for aural toilet under microscopic guidance
- Edema
- In cases in which edema has progressed to cause >50% narrowing of the canal, a medication wick may be necessary (e.g., Ό-inch ribbon gauze or compressed cellulose) to ensure adequate delivery of antimicrobial therapy directly to the epithelium.
- Do not use a cotton ball because it could fall apart and pieces could become trapped in the canal.
- The wick may fall out on its own as edema resolves or may be removed by clinician.
- Keep the area dry and refrain from swimming for the duration of treatment or at least until symptoms resolve.
- Refrain from using hearing aids until symptoms resolve.
Issues for Referral
Referral to an otolaryngologist may be indicated for aural cleaning, severe disease, treatment failure, or suspicion of malignant OE.
Ongoing Care
Follow-up Recommendations
- Reevaluate if symptoms do not improve within 48 hours of initiating treatment, progression of symptoms despite treatment, or severe illness.
- Immunocompromised patients should be followed closely due to risk for developing malignant OE.
Prognosis
- Excellent in uncomplicated OE with symptom improvement in 2 " 3 days and resolution of symptoms in 6 days
- Recurrence is common if steps are not taken to address predisposing factors.
Complications
- Stenosis of the ear canal, cellulitis, lymphadenitis, chondritis, parotitis, chronic OE (rare in children)
- Malignant OE in immunocompromised patients (also rare in children)
- Reaction to antibiotic preparation (pruritus, local reaction, rash, discomfort, otalgia, dizziness, vertigo)
Additional Reading
- Conover K. Earache. Emerg Med Clin North Am. 2013;31(2):413 " 442. [View Abstract]
- Ely JW, Hansen MR, Clark EC. Diagnosis of ear pain. Am Fam Physician. 2008;77(5):621 " 628. [View Abstract]
- Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database Syst Rev. 2010;(1):CD004740. [View Abstract]
- Long M. Otitis externa. Pediatr Rev. 2013;34(3):143 " 144. [View Abstract]
- Rosenfeld RM, Brown L, Cannon R, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2006;134(Suppl 4):S4 " S23. [View Abstract]
- Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014;150(1)(Suppl):S1 " S24.
- Schaefer P, Baugh R. Acute otitis externa: an update. Am Fam Physician. 2012;86(11):1055 " 1061. [View Abstract]
Codes
ICD09
- 380.10 Infective otitis externa, unspecified
- 380.12 Acute swimmers ' ear
- 380.16 Other chronic infective otitis externa
- 380.22 Other acute otitis externa
- 380.23 Other chronic otitis externa
- 380.13 Other acute infections of external ear
ICD10
- H60.90 Unspecified otitis externa, unspecified ear
- H60.339 Swimmer 's ear, unspecified ear
- H60.509 Unsp acute noninfective otitis externa, unspecified ear
- H60.60 Unspecified chronic otitis externa, unspecified ear
- H60.21 Malignant otitis externa, right ear
- H60.63 Unspecified chronic otitis externa, bilateral
- H60.22 Malignant otitis externa, left ear
- H60.93 Unspecified otitis externa, bilateral
- H60.92 Unspecified otitis externa, left ear
- H60.91 Unspecified otitis externa, right ear
- H60.20 Malignant otitis externa, unspecified ear
- H60.62 Unspecified chronic otitis externa, left ear
- H60.319 Diffuse otitis externa, unspecified ear
- H60.23 Malignant otitis externa, bilateral
- H60.61 Unspecified chronic otitis externa, right ear
SNOMED
- 3135009 Otitis externa (disorder)
- 194201001 Acute swimmers ear (disorder)
- 30250000 Acute otitis externa
- 53295002 chronic otitis externa (disorder)
- 94146005 Malignant otitis externa
- 86981007 Infective otitis externa (disorder)
FAQ
- Q: How should I clean my child 's ear?
- A: The external ear can be cleaned with a washcloth. Cotton swabs or other objects should not be inserted into the ear canal, as they may cause trauma or lead to impaction of cerumen. If there is concern for impacted cerumen causing symptoms such as ear fullness, pain, or hearing loss, then a physician should be consulted for discussion of methods for removal.
- Q: Is there a role for oral antibiotics in the treatment of OE?
- A: In uncomplicated OE where the infection is limited to the external canal, topical antibiotics are sufficient. If infection extends beyond the external canal (e.g., otitis media or cellulitis), then an oral antibiotic is advised.
- Q: How should treatment of OE differ if one cannot visualize the tympanic membrane due to accumulated debris and/or edema?
- A: In cases where the tympanic membrane cannot be confirmed to be intact, do not perform lavage. Debris can be removed by curette in the primary care physician 's office or the patient may be referred to an otolaryngologist for removal under microscopic guidance. Choose a topical antimicrobial agent other than an aminoglycoside due to its toxic effects on the middle ear. Depending on the certainty of your diagnosis of OE, consider whether the history suggests a coexisting acute otitis media necessitating presumptive treatment with oral antibiotics.