Background

Otitis externa is an infection of the external auditory canal. Prompt diagnosis and treatment cures the
majority of cases without complication. However, patients who are diabetic, immunocompromised, or
untreated may develop malignant otitis externa, a potentially life-threatening infection. 

Otitis externa is defined as chronic when the duration of the infection exceeds 4 weeks or when more
than 4 episodes occur in 1 year.

Pathophysiology
The ear canal guards against infection by producing a protective layer of cerumen, which creates an
acidic and lysozyme-rich environment. While a paucity of cerumen allows for bacterial growth, an
excess can cause retention of water and debris, which can create an environment ideal for bacterial
invasion. This may happen when the ear canal is regularly exposed to water as seen in swimmers
and divers. Localized trauma from foreign objects placed in the ear can also lead to direct bacterial
invasion in the ear canal. Once an infection becomes established, localized maceration and
inflammation occur, which lead to symptoms. 

Rarely, the bacterial infection can invade the deeper underlying structures of the soft tissue and
destroy the underlying temporal bone. This is called malignant otitis externa and is a complication
seen more often in immunocompromised patients. 

The most common organism reported in otitis externa is the Pseudomonas species, followed

by Staphylococcusand Streptococcus species. Fungi are a less common cause of otitis externa.1

Frequency
United States

Acute otitis externa occurs in 4 of every 1000 people annually, and the chronic form affects 3-5% of
the population.2  The condition is most common in swimmers, divers, and those whose ears are
regularly exposed to or submerged in water.

Mortality/Morbidity
If left untreated, the infection may invade the deeper adjacent structures and progress into malignant
otitis externa. This complication is almost exclusively seen in immunocompromised patients such as
those with diabetes, AIDS patients, those undergoing chemotherapy, and patients taking
immunosuppressant medications such as glucocorticoids. Pseudomonas is the inciting organism in
the vast majority of cases. When untreated,malignant otitis externa has a mortality rate approaching
50%. This complication should be suspected if tenderness, erythema, or edema of the external ear or
adjacent tissues is present on physical examination.

Race
People in some racial groups have small ear canals, which may predispose them to obstruction and
infection.

Sex
Rates of occurrence of otitis externa are equal in males and females.

Age
Although otitis externa is seen in all age groups, the peak incidence is in children aged 7-12 years. 1
Clinical

History

 In general, a history of 1-2 days of progressive ear pain

 Frequently, a history of exposure to or activities in water, such as swimming, surfing, and
kayaking
 Pruritus within the ear canal
 Purulent discharge
 Conductive hearing loss
 Feeling of fullness or pressure

Physical

 The sine qua non of otitis externa is pain on gentle traction of the external ear structures.
 Periauricular adenitis may occur but is not necessary for the diagnosis.
 Examination of the canal reveals erythema, edema, and narrowing of the external auditory
canal.
 Typically, accumulation of moist debris is observed in the external canal.
 The tympanic membrane may be difficult to visualize and may be mildly inflamed, but it
should be normally mobile on insufflation.
 Spores and hyphae may be seen in the external canal if the etiology is fungal.
 Eczema of the pinna may be present.
 By definition, cranial nerve (CN) involvement (ie, of CNs VII and IX-XII) is not associated with
simple otitis externa.

Causes

 Traumatized external canal (particularly due to cotton-tipped swabs)

 Bacterial infection
o Pseudomonas species (38% of all cases)1
o Staphylococcus species
o Gram-negative rods
 Fungal infection (rare, 10%) -Aspergillus species
 Yeast (rare) -Candida species
 Eczematous otitis externa
o Eczema
o Seborrhea
o Neurodermatitis
o Contact dermatitis from earrings or hearing aid use
o Purulent otitis media with perforation of the tympanic membrane and drainage (This
may mimic findings in otitis externa, but it is usually painless and has no swelling of
the canal.)
o Sensitivity to topical medications