Otitis Externa

Otitis externa is a condition that occurs when the external ear canal, the channel between the outer ear and the eardrum, becomes inflamed. The condition is typically the result of a bacterial or fungal infection, but can also be caused by irritation or allergies. 1 As repeated exposure to water can make otitis externa more likely, the condition is commonly referred to as swimmer’s ear.

Symptoms include pain in the ear, itchiness in the ear canal, partial hearing loss and a discharge of pus or liquid. While it can cause severe discomfort, most cases of otitis externa resolve in under a week. 2 While ear drops are the most common treatment method, other options are also available for severe cases or when the condition is chronic or recurrent.

Otitis externa should not be confused with the most common type of ear infection, otitis media. Also known as a middle ear infection, otitis media affects the air-filled cavity behind the eardrum. For more information, take a look at this comprehensive otitis media resource.

There are three main sub-varieties of otitis externa, each defined by the length of time the condition is experienced: 1

• Acute otitis externa lasts for under three months, although usually for around one week.
• Recurrent otitis externa causes symptoms of the condition to be present in persistent bouts, each lasting for under three months.
• Chronic otitis externa is diagnosed when the condition lasts for more than three months. In severe cases, it can last for a number of years.

Acute otitis externa is the most common form of the condition. 3

Typical symptoms of swimmer’s ear include: 1 2 3

• Ear pain, which can range from mild to severe
• Partial hearing loss
• A feeling of fullness or pressure in the ear
• Itching and/or irritation in and around the ear
• Discharge from the ear, which can be thin and watery or thick and pus-like, and may be foul smelling
• A ringing in the ears, known as tinnitus
• Swollen neck glands
• Scaly skin in and around the ear
• Fever, although this is uncommon

Both ears can be affected by otitis externa, but it is most common to experience symptoms in only one ear. The length of time that symptoms will last for depends on the type and severity of a person’s condition.

People who may be experiencing the symptoms of otitis externa should see their healthcare provider. In addition, they can use the free Ada app to carry out a symptom assessment.

Otitis externa is typically caused by infection. The ear canal, a narrow, warm channel connecting the outer ear and the eardrum, is an ideal place for bacteria and fungi to grow. 1 Bacteria, particularly Pseudomonas aeruginosa and Staphylococcus aureus, are the most common cause of infection, but fungal infections from varieties such as Aspergillus and Candida albicans are also possible. 2

The condition may also be caused by seborrhoeic dermatitis, a common skin condition that causes irritation and inflammation of the skin. Irritation or an allergic reaction can also cause otitis externa. This could be a result of a particular shampoo, medication or sweat, for example.

Certain factors and activities can increase a person’s likelihood of developing otitis externa: 1 2 4

• Swimming. People who swim regularly stand a higher chance of developing otitis externa, particularly those who swim in unsanitary water. This is why the condition is commonly known as swimmer’s ear.
• Warm weather. Otitis externa is more common in countries with warm or humid climates. The moisture that results from sweating or humidity can create a good environment for bacteria or fungi to grow.
• Ear damage. Damage to the ear canal as a result of excessive scratching, the use of cotton ear swabs or long-term use of earbuds, for example, may increase the risk of otitis externa.
• Skin conditions. In addition to seborrhoeic dermatitis, skin conditions such as acne, eczema or psoriasis, can make otitis externa more likely.
• Excessive earwax. People with large amounts of earwax in their ears are more at risk. Although it normally serves to protect the ear canal from infections, excessive earwax can trap the bacteria that can cause infection.
• Otitis media (middle ear infection). Occasionally, otitis media can produce a discharge which gets trapped in the ear canal, causing otitis externa.
• Weakened immune system. People with a condition that weakens the immune system, such as HIV or diabetes, can be more likely to develop otitis externa.

A diagnosis of otitis externa will usually be based upon the symptoms present and a physical examination. This will often involve an otoscopy, a procedure in which a small, tubular torch, known as an otoscope, is used to examine the interior of the ear canal and eardrum. A tympanometry may also be used. This is an examination technique in which air pressure is used to test the condition and mobility of the middle ear. 5

In some instances, tests may also be run on the ear’s discharge in order to identify the type of bacterium or fungus causing the infection.

People displaying symptoms of otitis media should consult a doctor. Treatment is aimed at relieving any pain, reducing inflammation and preventing the condition from recurring. 6 The exact course that treatment will take, however, depends on the condition’s severity, as well as whether it is acute, chronic or recurrent in nature.

Before treatment is begun, the ear canal of the affected person may require cleaning. This helps to clear the residual discharge, allowing the treatment to be more effective. The method used to clean the ear canal will depend on the severity of the condition, but will typically involve swabbing, suction or the use of a syringe.

Some of the most common treatment methods for otitis externa include:

Although ear drops can be bought over-the-counter, stronger, antibiotic and steroid containing ear drops may be prescribed by a doctor. The antibiotic is able to fight the infection, while the steroid element is designed to control the inflammation. Typically, ear drops will take around a week to clear the symptoms. If this does not happen, the doctor may prescribe a different type of ear drops. 1

Alternatives to antibiotic medications may be prescribed. If it is suspected that the condition is being caused by overuse of antibiotics, or a skin condition such as eczema or psoriasis, steroid-only ear drops may be preferred. If a fungal infection is the cause, antifungal ear drops will likely be prescribed.

It is important for the ear drops to be administered correctly for them to work effectively. To use ear drops, the affected person should: 1 6

• Lie on their side, with the affected ear pointing upwards
• Place the ear drops into the ear canal and remain in the same position for roughly 10 minutes
• Press down on the cartilage on the front of the ear to ensure the ear drops have entered the ear canal

If the ear canal is severely swollen or blocked, an ear wick may be required to administer the drops. This involves inserting a medication-soaked gauze into the ear canal, ensuring the drops are able to make contact with the affected area and work effectively. The gauze will typically need to be changed every two to three days. 1

Before beginning the use of ear drops, be sure to read the instructions contained within the packaging. If the drops contain antibiotics, it is also important to finish the prescribed course, even if the condition clears before this time. This prevents your body from building up an immunity.

Oral antibiotics will only be prescribed in particularly severe cases, or if there is a risk of the infection spreading outside of the ear canal. This may be in addition to ear drops. It is important to read the instructions enclosed within the packaging carefully and to complete the whole course, even if symptoms disappear before this time.

In particularly severe cases, a doctor may refer the affected person to an ear, nose and throat specialist, an otolaryngologist, for specialist treatment. 4 This may also be the case if an episode of otitis externa does not respond to treatment, or if a person is experiencing the recurrent or chronic forms of the condition.

If it is a mild case, the doctor may recommend treating the condition at home before prescribing any specific medication. This may involve the use of over-the-counter ear drops or sprays, as well as painkillers such as paracetamol or ibuprofen. Placing a warm towel against the affected ear may also help to reduce pain.

Keeping the affected ear dry is also important in helping the symptoms to clear. Take care while in the shower or bath, and refrain from swimming completely. Water, especially dirty water, tends to exacerbate the condition.

There are several things a person can do to help prevent otitis externa: 1 4

• Do not attempt to clean the ear canal. The ears are self-cleaning. The use of cotton ear swabs, towels, fingers or anything else to clean the inside of the ears is unnecessary and potentially damaging. If a person feels there is excessive wax in the ears, they should talk to a doctor before attempting to clean the ears themselves.
• Keep the ears dry. After swimming, shake the head to ensure all water is emptied from the ears. A hair-dryer on a low heat setting can also be used to make sure the ears are completely dry. Regular swimmers, especially those swimming in water that may not be clean, should also consider the use of swimmer’s ear plugs.
• Use preventative ear drops. Acetic ear drops, available from pharmacies, can help to prevent otitis externa. These drops should be applied before and after swimming.

Otitis externa is typically a non-serious condition. There is, however, a small risk of complications. Possible complications of otitis externa include: 2 7

A pus-filled abscess can, in some cases, form in and around the affected ear. Abscesses can be painful and may spread to other areas of the body.

While small abscesses may resolve on their own, larger abscesses will often require the attention of a doctor. A doctor will typically drain the pus and may prescribe antibiotics to clear the infection and prevent spreading.

Otitis externa can cause thick, dry skin to accumulate in the ear canal, leading to a narrowing of the channel. This is called stenosis. If this happens, the affected person may experience a temporary loss of hearing, and in very rare cases, deafness. Stenosis is usually treated using ear drops.

In rare cases, usually when the condition is chronic, the infection can spread to the eardrum. If this happens, discharge can buildup within the inner ear, causing the eardrum to rupture, or perforate.

Symptoms of a perforated eardrum may include:

• Hearing loss
• Pain in the ear
• Discharge from the ear
• Ringing in the ear

A perforated eardrum will usually heal on its own in around two months. During this time, no liquid should enter the ear. Due to this, doctors may prescribe oral antibiotics to treat the infection itself. Over-the-counter painkillers can be used to manage any discomfort.

Otitis externa can cause the skin to become damaged. When bacteria from the surface of the skin is able to move into its deeper layers through this damaged skin, cellulitis can occur. Symptoms of cellulitis include:

• Red, painful and tender skin around the affected area
• Nausea
• Shivering and chills
• Malaise

People experiencing symptoms of cellulitis should consult a doctor. Typically, the condition will be treated with a short course of antibiotics.

Malignant otitis externa is a serious but very rare complication. It occurs when the infection spreads to the bone surrounding the ear canal. People with weakened immune systems, such as people diagnosed with HIV, people undergoing chemotherapy treatment and people with diabetes, especially older people with poor glucose control, are most at risk.

Signs and symptoms of malignant otitis externa include:

• Headaches
• Severe ear pain
• Exposed bone in the ear canal
• Drooping of the face on the side of the affected ear, called facial nerve palsy

Malignant otitis externa must be treated immediately. This is usually done using intravenously administered antibiotics or, if antibiotics prove ineffective, surgery. Left untreated, malignant otitis externa can be fatal.

Q: Are swimmer’s ear plugs effective in preventing otitis externa?
A: Although they cannot guarantee complete protection, ear plugs are an effective way of preventing water from entering the ear canal, and thus of preventing otitis externa. It is important to clean the ear plugs with water, and if necessary a mild soap, after each use. They should also be completely dry before use.

Q: Can otitis externa cause dizziness?
A: Generally, dizziness is not associated with otitis externa. Dizziness usually stems from a problem with the inner ear, in otitis externa, the affected area is separated from the inner ear by the eardrum and ear canal.