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Otitis externa
Jill Gore, MPAS, PA-C
GENERAL FEATURES
• Otitis externa, commonly called swimmer’s ear, is an
inflammation of the external auditory canal most com-
monly caused by an acute bacterial infection. Other
causes include fungus (otomycosis), virus, allergy, or a
dermatologic disease.
• Affects 10% of the population, most commonly children
• Highest incidence is during the summer
• Risk factors
° swimming or other water exposure
° high temperature or humidity
° absence of cerumen
° trauma from excessive cleaning or scratching of the
external auditory canal
° objects that occlude the external auditory canal includ-
ing hearing aids, earphones, or diving caps
° dermatologic conditions such as psoriasis and eczema
° previous radiation therapy.
• Bacteria most commonly implicated are Pseudomonas
aeruginosa, Staphylococcus epidermidis, and S. aureus.
Anaerobes also can be present.
• Up to 10% of otitis externa is due to fungus, most com-
monly Aspergillus. Candidal infections typically affect
patients who wear hearing aids.
HISTORY AND PHYSICAL EXAMINATION
• Symptom onset is usually rapid, generally within 48 hours.
• Ear pain, discharge, and hearing loss are the most com-
mon symptoms. In patients with otomycosis, pruritus is
more common than pain.
• On examination, the patient may have a conductive
hearing loss due to swelling and narrowing of the exter-
nal auditory canal.
• Tenderness with tragal or auricle movement is the hall-
mark of otitis externa.
• On otoscopic examination, the external auditory canal
may be edematous and erythematous. Debris, discharge,
or maceration may be present. The tympanic membrane,
if visible, may be erythematous.
• In otomycosis caused by Aspergillus, the external audi-
tory canal will have a fine, white mat topped with dark
Jill Gore practices at RediClinic in San Antonio, Tex. The author has
disclosed no potential conflicts of interest, financial or otherwise.
Dawn Colomb-Lippa, MHS, PA-C, department editor
DOI:10.1097/01.JAA.0000529781.69812.8e
Copyright © 2018 American Academy of Physician Assistants
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2018 American Academy of Physician Assistants
spheres. In Candida otomycosis, a white, sebaceous-like
material will be present.
DIAGNOSIS
• Clinical, based on history and physical examination
• Cultures are reserved for patients with severe cases of
otitis externa, recurrent otitis externa, chronic otitis
externa, immunosuppressed patients, otitis externa in a
patient after ear surgery, and in patients who do not
respond to initial therapy.
TREATMENT
• Antimicrobials
° Because the infection is limited to the external auditory
canal, a topical antibiotic, with or without a cortico-
steroid, is the mainstay of treatment.
° Minimal adverse reactions
° Minimal clinical difference between various topical
agents. Frequency of dosing depends on the agent used.
Treatment duration is for 7 days and may continue for
up to 14 days for unresolved symptoms.
° Fluoroquinolones (ofloxacin and ciprofloxacin) and
aminoglycosides (tobramycin, gentamicin, and neo-
mycin/polymyxin B) are effective against the two most
common causes of otitis externa. Ototoxicity is a
concern with aminoglycosides.
° Topical corticosteroids (hydrocortisone, dexamethasone,
prednisolone) decrease inflammation, resulting in less
pruritus and pain. These can be prescribed separately
or in combination with antibiotics.
QUESTIONS
1. Which of the following is not a clinical finding in acute
otitis externa?
a. pain with tragus or auricle movement
b. discharge from affected ear
c. fever
d. decreased hearing
2. Which topical otic medication can be used in a patient
with otitis externa and tympanic membrane perforation?
a. chloroxylenol, pramoxine, and hydrocortisone
b. ciprofloxacin and dexamethasone
c. ciprofloxacin and hydrocortisone
d. polymyxin B, neomycin, and hydrocortisone
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° If the tympanic membrane is perforated or is not visible
due to canal swelling or debris, ofloxacin or cipro-
floxacin/dexamethasone is recommended.
° For otomycosis, topical clotrimazole 1% solution,
applied twice daily for 10 to 14 days, is recommended.
• Wick placement
° Patients with severe external auditory canal swelling
should have a wick placed in the canal to allow topical
medication to reach the site of infection. Replace the
wick every 2 to 3 days until the swelling has improved.
• Pain control
° NSAIDs are the mainstay of therapy to treat associated
pain.
• Activities
° The external auditory canal should be kept dry during
treatment and for 1 to 2 weeks after treatment. An
earplug or a cotton ball coated with petroleum jelly
can be placed in the external auditory canal during
bathing or showering.
° Patients involved in aquatic activities may return 2 to
3 days after starting treatment and should keep their
heads above water or wear earplugs.
° Hearing aids and earphones may be worn once pain
and discharge have resolved.
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PROGNOSIS AND COMPLICATIONS
• Most patients begin to improve within 48 to 72 hours,
with full resolution of symptoms within 7 to 10 days.
• Patients who have diabetes, are immunocompromised,
have had radiotherapy to this region, or whose otitis
externa is not treated may develop necrotizing (malignant)
otitis externa. In this life-threatening condition, bacteria
invade the deeper underlying structures and cause osteo-
myelitis. Suspect necrotizing otitis externa if the patient’s
pain is out of proportion to the clinical appearance or if
granulation tissue is seen in the ear canal. Overall mortal-
ity is 50%. JAAPA
debris.
the membrane is not visible due to canal swelling or
for patients with tympanic membrane perforation or if
2. B. Ciprofloxacin and dexamethasone is recommended
include ear pain, discharge, and hearing loss.
hallmark of the condition; other signs and symptoms
Tenderness with tragal or auricle movement is the
1. C. Fever is not a clinical finding in acute otitis externa.
Answers
Volume 31 • Number 2 • February 2018