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Otitis externa (OE) is a common disease affecting all age groups. OE usually represents an acute bacterial infection of the skin of the ear canal but can be caused by a fungal infection. Although OE rarely causes prolonged problems or serious complications, the infection is responsible for significant pain and acute morbidity.
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Pathophysiology
OE is a superficial infection of the skin in the ear canal. Two common initiating events may lead to OE. If trapped in the ear canal, moisture may cause maceration of the skin and provide a good breeding ground for bacteria. This may occur after swimming (especially in contaminated water) or bathing, hence the common lay-term swimmer's ear. It may also occur in hot humid weather (when OE is more prevalent). The second significant factor is trauma to the ear canal that allows invasion of bacteria into the damaged skin. This often occurs after attempts at cleaning the ear with a cotton swab, paper clip, or any other utensil that can fit into the ear. Once infection is established, an inflammatory response occurs with skin edema. Exudate and pus often appear in the ear canal as well. If severe, the infection may spread and cause a cellulitis of the face or neck. The most common pathogen is Pseudomonas aeruginosa, followed by Staphylococcus aureus, then other gram-negative organisms. Occasionally, fungi, such asCandida or Aspergillus species, cause OE. Necrotizing (or malignant) OE is a complication that occurs in patients who are immunocompromised or in those who have received radiotherapy to the skull base. In this condition, bacteria invade the deep soft tissues and cause osteomyelitis of the temporal bone. This is a life-threatening disorder with an overall mortality rate that approached 50% historically.

Epidemiology
Frequency
United States OE is a very common disease that occurs in all regions of the United States. The infection is believed to be more prevalent in hot and humid conditions. International Although OE is a very common disease that occurs worldwide, the infection is believed to be more prevalent in hot and humid conditions.

Mortality/Morbidity
OE can cause severe otalgia requiring narcotic pain relievers in some patients. Temporary hearing loss is common secondary to canal occlusion. Severe infections may cause lymphadenitis or cellulitis of the face or neck. Necrotizing OE is a serious condition that requires prolonged treatment and often results in severe morbidity or mortality.

Race
No racial disposition is known.

Sex
OE affects both sexes equally.

Age
Although the infection can affect all age groups, OE appears to be most prevalent in the older pediatric and young adult population.

History
Patients with otitis externa (OE) may complain of the following: Otalgia ranging from mild to severe Hearing loss Ear fullness or pressure Tinnitus Fever (occasionally) Ear discharge Itch (especially in fungal infections or chronic OE) Severe deep pain (If experienced by a patient who is immunocompromised or diabetic, be alerted to the possibility of necrotizing OE.)

Physical
Characteristics of OE present upon physical examination may include the following: Pain upon palpation of the tragus (anterior to ear canal) or when applying traction to the pinna (hallmark of OE) Edema and redness of the ear canal

Acute otitis externa. The ear canal is red and edematous, and discharge is present.

o o o o o

Purulent or serous discharge in the ear canal Conductive hearing loss Cellulitis of the face or neck or lymphadenopathy of the unilateral neck (in some patients) Fungal OE characteristics include the following: Fungal infections result in severe itch but less pain than bacterial OE. A thick discharge that may be white or gray is often present. Upon close examination, the discharge may have visible fungal elements or a fuzzy appearance. Necrotizing (malignant) OE characteristics include the following: The sine qua non of necrotizing OE is pain out of proportion to clinical findings. Upon close examination, granulation tissue may be present in the ear canal.

Causes
Risk factors for OE include swimming (hence, the commonly used term swimmer's ear), any source of water trapped in the ear canal, trauma to the ear canal, and a hot humid environment. Causative organisms for OE: These are usually Pseudomonas species,S aureus, or other gramnegative organisms. Fungal OE o Fungal OE may result from overtreatment of the ear canal with topical antibiotics, or it occasionally may present de novo from moisture trapped in the ear canal. o The most common organisms involved with fungal OE are Candidaand Aspergillus species; however, many others have been isolated. Chronic OE

Chronic OE is a fairly common condition that may be the result of incomplete treatment of acute OE.[2] o However, chronic OE more often is caused by overmanipulation of the ear canal due to cleaning and scratching. o This results in a low-grade inflammatory response that further causes itching of the skin. o Eventually the skin thickens, and canal stenosis may occur. Necrotizing OE: Necrotizing OE occurs in patients who are immunocompromised and represents a true osteomyelitis of the temporal bone.

Laboratory Studies
Most persons with otitis externa (OE) are treated empirically. A culture taken from the ear canal discharge may be helpful in individuals with OE that is not responding to the usual measures.

Imaging Studies
Imaging studies are only performed in persons with suspected necrotizing OE (ie, malignant). Classically, radionucleotide bone scan and gallium scan have been used to make the diagnosis. Currently, high-resolution CT scanning of the temporal bone plays a more important role. Although MRI has not been used to the same extent as these other tests, MRI may also be useful.

Procedures
Use of an ear wick helps topical medication penetrate a severely swollen ear canal. The wick may be commercially prepared from a hard sponge material that expands when wet (eg, Merocel ear wick, Pope Oto-Wick), cut from a bigger sponge by the physician, or made from a narrow packing gauze. The wick is placed in the ear canal (unfortunately, this causes brief but significant discomfort) and is moistened with topical antibiotic eardrops. The ear wick usually is removed after 2-3 days.

Medical Care
Topical treatment Most cases of acute otitis externa (OE) respond well to topical treatment. Antibiotic eardrops, with or without a steroid, are the mainstay of treatment. Topical acidifying and drying agents may be used in mild or resolving cases and are useful in fungal infections. Some patients require strong analgesics for the first few days of treatment. Oral antibiotics Most persons with OE do not require oral medications. Administer oral antibiotics in individuals with cellulitis of the face or neck skin or in persons in whom severe edema of the ear canal limits penetration of topical agents. Consider oral antibiotics in patients who are immunocompromised. Intravenous antibiotics Intravenous (IV) antibiotics are used in individuals with necrotizing OE. They may also be appropriate in patients with severe cellulitis or in persons whose symptoms do not respond to topical and oral antibiotics. A prolonged course of IV antibiotics lasting as many as 6 weeks may be needed for individuals with necrotizing OE. If the patient is stable, IV antibiotics may be administered at home. Begin treatment with antibiotics to cover pseudomonads and alter medication depending on culture results.

Surgical Care
Debridement

Surgical debridement is occasionally required in individuals with necrotizing (ie, malignant) OE. Debridement of the ear canal is often necessary in more severe cases of OE or when a significant amount of discharge is present in the ear. An otolaryngologist usually performs debridement using magnification and suction equipment. Debridement is the mainstay of treatment for fungal infections. Incision and drainage Occasionally, an abscess forms in the ear canal. This usually occurs in OE caused by S aureus. The abscess often requires a simple incision and drainage procedure that is usually performed by an otolaryngologist using a needle or small blade.

Consultations
Consider consultation with an otolaryngologist for persons with severe OE or when the patient does not respond to treatment as expected. Debridement of the ear canal is often necessary for resolution of the infection (see Surgical Care). Necrotizing OE necessitates consultation with otolaryngology, infectious disease, and, in some instances, neurosurgery.

Activity
During treatment of OE and for 1-2 weeks following its resolution, advise the patient to keep the ear canal dry. During bathing or showering, advise the patient to place an earplug or cotton ball lightly coated with petroleum jelly in the ear canal to prevent water penetration.

Otic antibiotic agents

Class Summary
Most individuals with otitis externa (OE) may be treated with topical antibiotic preparations. Some preparations also contain a corticosteroid ingredient to decrease inflammation.

Hydrocortisone/neomycin/polymyxin
Antibacterial and anti-inflammatory solution for otic use. Treats superficial bacterial infections of external auditory canal. Available as solution or suspension.

Ofloxacin otic (Floxin Otic)

Pyridine carboxylic acid derivative with broad-spectrum bactericidal effect. Available as 0.3% (3 mg/mL) solution.

Ciprofloxacin otic (Cetraxal, Ciloxan)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA,Staphylococcus epidermidis, and most gram-negative organisms but with no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth. Available with or without hydrocortisone. Cetraxal otic solution available as 14 single-use applicators containing 0.25 mL of 0.2% solution each. Ciloxan is an ophthalmic solution that may be used for otitis externa.

Dexamethasone/tobramycin (TobraDex)
Tobramycin interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in defective bacterial cell membrane. Dexamethasone decreases inflammation by

suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. TobraDex is an ophthalmic solution that may be used for otitis externa.

Gentamicin ophthalmic (Garamycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Available as an ophthalmic solution that may be used for otitis externa.

Ciprofloxacin and dexamethasone otic (Ciprodex)

Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Has no activity against anaerobes. Dexamethasone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Ciprofloxacin and hydrocortisone otic suspension (Cipro HC Otic)

Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Has no activity against anaerobes. Hydrocortisone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Otic acidifying agents

Class Summary
These agents are useful in fungal OE or in mild infections believed to be bacterial. They can also be useful for prevention.

Acetic acid in aluminium acetate (Domeboro Otic)

Aluminium acetate has drying effect. Acetic acid works well in superficial bacterial infections of OE.

Hydrocortisone and acetic acid otic solution (VoSoL HC)

Acetic acid is antibacterial and antifungal; hydrocortisone is anti-inflammatory, antiallergic, and antipruritic. Works well in superficial bacterial infections of OE.

Alcohol vinegar otic mix

Homemade mix of 50% rubbing alcohol, 25% white vinegar, and 25% distilled water is as effective as pharmaceutical acidifying agents and less expensive. Very useful for prevention and can be used as flushing solution for funga

Oral antibiotics
Class Summary
These agents are used to treat severe infection or cellulitis. Fluoroquinolones are drugs of choice because of Pseudomonas species coverage.

Ciprofloxacin otic (Cipro)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms but with no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Further Outpatient Care

Monitor patients to ensure complete resolution. Usually a follow-up visit one week after starting treatment is adequate.

Deterrence/Prevention
Some patients acquire otitis externa (OE) multiple times and should use a preventive strategy. Earplugs worn for swimming and bathing are effective. Wipe earplugs with rubbing alcohol after use. Acidifying drops placed in the ear after swimming or bathing also have a prophylactic benefit.

Complications
Complications of OE are rare. As mentioned, cellulitis or lymphadenitis may occur and should be treated with an oral antibiotic therapy.

Prognosis
Most incidents of OE resolve without difficulty. Pain usually improves 2-5 days after initiating therapy. Most incidents of OE resolve in 7-10 days. In some patients with OE, the ear must be debrided prior to full resolution.

Patient Education
For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center Center. Also, see eMedicine's patient education articleSwimmer's Ear.