Definition

Otitis externa is inflamatory process of the external auditory canal.1

Classification

Otitis external may be classified on the basis of etiology, location and time course of the

illnes:2

1. Acute localised otitis externa (furunculosis): localised infection in the hair follicles in

the cartilaginous portion of the external auditory canal by S. aureus. The main

symptomp is otalgia and there is generally no otorrhea or deafness.
2. Acute diffuse otitis externa: infection is limited to the skin of the external auditory

canal.
3. Chronic otitis externa: occurs when there is incomplete resolution of the acute

infection or where there is a persisen infection and inflammation for more than 3

months. There is less pain but more profound itching and persistent discharge.

Examination reveals thickening of the canal skin of the ear canal. The chronic scaling

and itching in the canal perdispose the patient to manipulation of the canal,

excoriation and repeated episodes of acute otitis externa. With time the canal becomes

completely obliterated by the hypertrophic skin.

Patogenesis

The unique structure of the external auditory canal contributes to the development of otitis

externa. The external auditory canal is warm, dark and prone to becoming moist, making it an

excellent environment for bacterial and fungal growth. The skin is very thin and the lateral

third overlies cartilage, while the rest has a base of bone. The canal is easily traumatized. The

exit of debris, secretions and foreign bodies is impeded by a curve at the junction of the

cartilage and bone. The presence of hair, especially the thicker hair common in older men,

the canal is defended by a unique epithelial migration that occurs from the tympanic membrane outward. keratin debris absorbs the water. moderate or . the external auditory canal has some special defenses.can be a further impediment. otitis externa results. which creates a nourishing medium for bacterial growth. There are many precipitants of this infection. The lipid-rich cerumen is also hydrophobic and prevents water from penetrating to the skin and causing maceration. When these defenses fail or when the epithelium of the external auditory canal is damaged. Additionally. but cerumen that is excessive or too viscous can lead to obstruction. but the most common is excessive moisture that elevates the pH and removes the cerumen. Acute inflammatory stage is further divided into mild. carrying any debris with it. Too little cerumen can predispose the ear canal to infection. Senturia et al2 divided the clinical course of otitis externa into 3 stages: Acute inflammatory and chronic inflammatory. The outer third of the canal is cartilaginous with hair follicles and sebaceous and ceruminous glands.1 Anatomy of the external auditory canal. Cerumen creates an acidic coat containing lysozymes and other substances that probably inhibit bacterial and fungal growth. and infection. Once the protective cerumen is removed. Fortunately. retention of water and debris.

periauricular edema and cervical lymphadenopathy may also be present. The secretion. In the severe stage. will turn into a thick and seropurulent exudate. the lumen becomes obliterated due to the increasing edema and seropurulent material. a new pathogenic flora develops that is dominated by Pseudomonas aeruginosa and Staphylococcus aureus. the external auditory canal has a normal bacterial flora and remains free of infection unless its defenses are disrupted. The moderate state is accompanied by pain and auricular tenderness. initially clear and odourless. The patient complains of intense pain. The mild state is characterised by itch. oedema and a sensation of fullnes. Otalgia may be severe enough to require systemic analgesics such as codeine and nonsteroidal anti-inflammatory drugs (NSAIDs). especially on chewing.2 Etiology of Otitis Externa BACTERIAL OTITIS EXTERNA Like all skin. Fever. When disruption occurs. The canal becomes more oedematous and erythematous. Significant swelling of the .severe categories. The signs and symptoms of otitis externa with a bacterial etiology tend to be more intense than in other forms of the disease.

and the diagnosis is made by observing the unique discharge in the external auditory canal. The infection is often asymptomatic. which can be chronic.When symptoms are present.canal is common. fungus is occasionally the primary pathogen in otitis externa.1. Discharge and tinnitus are also common.2 NON INFECTIOUS OTITIS EXTERNA Otitis externa can also result from any of a broad range of noninfectious dermatologic processes. The most common pathogen is Aspergillus (80 to 90 percent of cases). Inflammatory skin disorders and allergic reactions may cause noninfectious otitis externa. resulting in scratching and further damage to the epidermis. but in fungal otitis externa this primarily takes the form of pruritus and a feeling of fullness in the ear. Classically. Lymphadenopathy just anterior to the tragus is common. The pruritus may be quite intense.1 Diagnosis . followed by Candida. Mixed bacterial and fungal infections are thus common. Fever may be present.1 FUNGAL OTITIS EXTERNA Fungi are identified in about 10 percent of cases of otitis externa. However. discomfort is again the most common complaint. especially in the presence of excessive moisture or heat. fungal infectios the result of prolonged treatment of bacterial otitis externa that alters the flora of the ear canal.

If inflammation causes sufficient swelling to occlude the external auditory canal. thick . Otomycosis is classically associated with itching. The ear discomfort can range from pruritus to severe pain that is exacerbated by motion of the ear. Its characteristics often may give a clue to its etiology. Because otitis externa can cause tympanic membrane erythema. Otorrhea is also quite variable. the patient may also complain of aural fullness and loss of hearing.The two most characteristic presenting symptoms of otitis externa are otalgia (ear discomfort) and otorrhea (discharge in or coming from the external auditory canal). pneumatic otoscopy or tympanometry should be used to differentiate it from otitis media. including chewing.

it also keeps the canal moist and interferes with topical treatment. Ear toilet Otorrhea and other debris can occlude the ear canal. Such occlusion makes it difficult to visualize the tympanic membrane and exclude otitis media. and failure to improve with use of topical antibacterials.material in the ear canal. However.1–3 Diagnosis Banding Conditions that may be confused with acute otitis externa:3 Treatment 1. . It is imperative that this material be removed. Otomycosis can sometimes be identified during otoscopy.

1 Treatment recommendations vary somewhat. topical antibacterial therapy should be started.5. When a wick is required. three to four drops are placed in the affected ear four times daily. fluoroquinolone agents. however.3 2. tinnitus. the ear canal should be reexamined and cleansed every two to five days until edema of the canal has . and a tympanic membrane already weakened by infection can easily be disrupted. flushing of the ear canal should not be attempted. are applied twice daily. a cotton swab with the cotton fluffed out can be used to gently mop out thin secretions from the external auditory canal. in patients with more severe infections.1. surfers and others who experience forceful compression of the tympanic membrane are particularly susceptible to perforations. however. Bacterial otitis externa Topical Treatment Once the external auditory canal has been cleansed as much as possible and a wick inserted if swelling is severe.2 Unless the tympanic membrane can be fully observed and is found to be intact. Divers. vertigo and dizziness.inflammation makes the external auditory canal even more vulnerable to trauma than usual. resulting in hearing loss. Cleansing is best done by suctioning. A small perforation is often missed. Usually. Alternatively.12 Flushing the ear when the tympanic membrane is perforated can disrupt the ossicles and cause significant cochlearvestibular damage. but it is most commonly recommended that drops be given for three days beyond the cessation of symptoms (typically five to seven days). The addition of steroids to the ear drops may decrease the inflammation and edema of the canal and resolve symptoms more quickly. 10 to 14 days of treatment may be required. and therefore the use of a cerumen spoon or curette should be avoided.1.

those taking systemic corticosteroids or if the disease has spread beyond the external auditory canal.1. At this time any further cleansing can be performed as needed. Otitis media should be considered when the patient has had an upper respiratory infection.2 4. such as those with diabetes.1. given three or four times daily for five to seven days.1 Systemic Treatment Oral antibiotics are rarely needed but should be used when otitis externa is persistent.6 Eardrops containing gentamycin/neomycin appear to be most effective against most common bacteria. when associated otitis media may be present or when local or systemic spread has occurred.Acidifying drops.3 3. Ciprofloxacin/ofloxacin otic solution is a new topical formulation that has a wide spectrum of activity against most common ear pathogens. the patient should be reevaluated at the end of the course of treatment. which also has some antibacterial activity. consideration also should be given to starting oral antibiotics early in patients whose immunity may be compro mised. and can be debilitating. Oral analgesics are the preferred treatment. if initial pain is severe or if regional lymphadenopathy of the preauricular or anterior or posterior cervical chains is present. can be used. over-the-counter clotrimazole 1 percent solution (Lotrimin). Analgesia Pain is a common symptom of acute otitis externa. First-line analgesics include nonsteroidal anti-inflammatory drugs . The latter should be suspected if the patient’s temperature is higher than 38°C. are usually adequate to complete treatment. Fungal Otitis Externa Cleansing of the ear canal by suctioning is a principal treatment. If the infection is not resolving.resolved and the wick is no longer needed. Because the infection can persist asymptomatically.

However. 2. otalgia and headache are disproportionately more severe than the clinical signs or when granulation tissue is apparent at the bony cartilaginous junction. despite adequate topical treatment. regardless of agent used. Thi is aimed at minimising ear canal trauma and avoidance of exposure to water.1–3 Prognosis Patients with uncomplicated diffuse otitis externa usually respond to treatment.2 CONCLUSIONS . all immunocompromised patients. are at risk. The diagnosis should be confirmed by a computed tomographic (CT) scan or magnetic resonance imaging (MRI). Most commonly caused by P.3 5. When ongoing frequent dosing is required to control pain.3 Complication Necrotizing or malignant otitis externa is a life-threatening extension of external otitis into the mastoid or temporal bone. Between 65% and 90% of patients have clinical resolution within 7 to 10 days. aeruginosa. and the mortality rate can be as high as 53 percent. Education Education is also important in preventing future episode. especially those with human immunodeficiency virus (HIV) infection. medications should be administered on a scheduled rather than as-needed basis.and acetaminophen. it is an osteomyelitis that occurs most often in elderly patients with diabetes mellitus. Necrotizing otitis externa is difficult to treat. This condition should be suspected when diffuse otitis externa.

Look for signs and symptoms indicating that the process extends beyond the external auditory canal. when used after exposure to moisture. REFERENCES . location and time course of the illness: Localised otitis externa. Avoid moisture and trauma in the external auditory canal to prevent recurrence. and evidence of an underlying systemic dermatologic process. Acidification with 2 percent acetic acid combined with hydrocortisone for inflammation is effective treatment in most cases and. Otitis externa is inflamatory process of the external auditory canal. Discomfort limited to the external auditory canal is the most characteristic symptom. is an excellent prophylactic. acute otitis externa. Thorough cleansing of the external auditory canal whenever possible is essential for diagnosis and treatment. The two most characteristic presenting symptoms of otitis externa are otalgia (ear discomfort) and otorrhea (discharge in or coming from the external auditory canal). severe pain or granulation of the external auditory canal in patients with diabetes or those who are immunocompromise. diffuse otitis externa. including: Evidence of associated otitis media on otoscopic examination. chronic otitis externa and noninfectious otitis externa. Otitis external may be classified on the basis of etiology.

3.1016/0196-0709(92)90115-A. 2001. 2012. doi:10. Acute otitis externa: An update. Ong YK. 2. Otitis externa: a practical guide to treatment and prevention. Sander R. Chee G. Infections of the external ear.34(4):330-334. Schaefer P. . Baugh RF. Am Fam Physician. Ann Acad Med Singapore. 2005.86(11):1055-1061.1. Am Fam Physician.63(5):927-936-942.