This article is on otitis externa, inflammation of the outer ear. This resource is open to everyone. Patients, medical students and health professionals may find this useful. Adjacent boxes provide additional information for Medical Professionals.

 

What is Otitis externa?

The outer ear includes the opening of your ear and the tube inside up to the eardrum (the ear canal).

Inflammation or infection of the outer ear is called otitis externa, or swimmer’s ear.

 

Who gets Otitis externa?

Otitis externa can happen at any age. The infection is usually due to bacteria and sometimes, fungus.

The outer ear is lined with a layer of skin, which is always replacing itself. This produces earwax or cerumen. Earwax is helpful in trapping particles and creating an environment that limits bacterial growth.

When water gets trapped in the outer ear (e.g. through swimming or showering/bathing), it turns the outer ear into a moist, warm, and dark area that bacteria grow well in. Damage to the skin of the outer ear (e.g. through itching or using cotton buds) also helps bacteria find areas to grow.

Things that can increase your risk of getting otitis externa includes:

  • Lots of swimming
  • Itching / scratching of the ear or cleaning with cotton buds
  • In-ear devices, like hearing aids or headphones
  • Irritating chemicals, like some shampoos
  • Skin conditions (e.g. atopic dermatitis, psoriasis, eczema)
  • Underlying health conditions that affect your ability to fight infections, including diabetes, radiotherapy, or chemotherapy

 

What are the causes?

Things that put you at higher risk of middle ear infections are:

  • Exposure to cigarettes / tobacco
  • Going to daycare / kindergarten
  • Crowded, damp housing
  • Family history
  • Allergic history (e.g. eczema, asthma, hayfever, etc.)
  • Sick often (e.g. colds, infections)
  • Underlying medical conditions (e.g. cleft palate, Downs Syndrome)

Breastfeeding seems to protect against middle ear infections. The effect of this is greatest up to six months old, and until the age of two.

 

What are the symptoms?

Otitis externa can cause a range of symptoms, depending on how bad it is.

Most people will have ear pain, usually only in one ear. You may notice it more if you touch your ear, or while you are eating. Some people have hearing loss. The ear may feel itchy, be swollen or red. Some people have fluid or pus coming out from the ear. Some people also get fever.

 

How is it diagnosed?

Otitis externa is diagnosed from the patient’s story and by looking inside the ear. Your doctor may ask you about other medical conditions, recent treatment and if you use any in-ear devices (including cotton buds).

Doctors will use an otoscope, which allows a good view of the ear canal and eardrum. They will probably see a red and swollen ear canal in otitis externa. Looking inside the ear also helps doctors rule out other causes for symptoms (e.g. a middle ear infection).

A doctor may also take a swab of the ear, to make sure any treatment is targeting the right bacteria. This usually happens if someone has repeat infections despite treatment.

 

What are the potential complications?

Otitis externa can sometimes cause an infection of the skin surrounding the ear (cellulitis). This requires antibiotics to treat.

A rare but dangerous complication is malignant otitis externa. This is most common in people who have weak immune systems or in diabetic adults. In these cases, the infection spreads to the bones and soft tissues of the skull, outside of the ear. Apart from ear pain, this can cause different symptoms like dizziness or weakness in the muscles of your face. In these cases, referral to a specialist is usually needed. They may order blood tests and special scans (e.g. MRI or CT).

 

What are the treatment options?

With the right treatment and depending on how bad it is, an episode of otitis externa clears up in one to two weeks. The symptoms may take a week to go. It is important to take regular pain relief while the infection is clearing.

Treatment involves eardrops. The eardrop that your doctor recommends depends on how bad the episode is. Eardrops may be a steroid, antibiotic, or a combination of both. Your doctor may also do other things to make it easier for medication to have its best effect. This includes giving the ear a good clean out prior to putting in eardrops. They may also put a wick in the ear. A wick is like a sponge, which soak medication for greater effect.

Other things to may help:

  • Keeping the ear dry. This might be avoiding swimming or other activities where water might get into the ears. You may like to use ear plugs.
  • Don’t put cotton buds in the ears
  • Limit wearing in-ear devices and clean them often (e.g. hearing aids, headphones)

 

Can you prevent Otitis externa?

Preventing otitis externa can be difficult. If you have repeat infections or you often get water in your ears, some things you can do are:

  • Limit wearing in-ear devices and clean them often (e.g. hearing aids, headphones)
  • Wearing ear plugs when swimming or showering to stop water from getting into the ear
  • Some people suggest drying the ear with a hair dryer at the lowest power and holding it 30cm away.
  • Avoid putting things inside the ear – especially cotton buds
  • See your doctor about other medical conditions that may not be under control (e.g. allergies, skin conditions)

 

What is the prognosis?

Otitis externa can take one or two weeks to clear up. Eardrops will help with this.

 

Impact on DALY

If your work or hobby includes water activities (e.g. swimming, diving, etc.), you may need to avoid this until the infection clears up. You may also need to start wearing ear plugs to help keep water out when you return to the activity.

If you wear in-ear devices, you may need to limit how often you wear them. This may be a problem for things like hearing aids. Make sure to clean them often and take them off while you sleep.

 

Further reading:

https://www.healthnavigator.org.nz/health-a-z/e/ear-infection-outer-ear/

 

References:

https://journals.sagepub.com/doi/pdf/10.1177/0194599813517083
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4466798/

 

Author + Affiliation:
Brian Yeom, MBChB BMedSc(Hons). Counties Manukau Health

Date of Publication +/- Review:

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Otitis externa

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