Otitis externa (OE), or “swimmer’s ear,” is an inflammatory condition of the auricle and EAC, often with an accompanying infection (bacterial or fungal). Typical symptoms include otalgia, pruritus, otorrhea, and hearing loss. Physical examination reveals EAC hyperemia and edema, otorrhea, occlusion from debris and swelling, pain with manipulation of the tragus, and periauricular lymphadenopathy.
Several factors predispose the EAC to infection: increased humidity and heat, repeated water immersion, foreign bodies, in-ear headphone, trauma, hearing aids, and cerumen impaction. Bacterial OE is primarily an infection due to Pseudomonas species or Staphylococcus aureus. Patients with diabetes are particularly prone to infections by Pseudomonas, Candida albicans, and, less commonly, Aspergillus niger.
Management and Disposition
EAC irrigation and suctioning are recommended to thoroughly evaluate the EAC. Topical antibiotic suspensions containing polymyxin, neomycin, and hydrocortisone or ciprofloxacin with ear wicks are effective. Topical solutions are not pH balanced and thus are irritating and may cause inflammation in the middle ear if a perforation is present. Topical fluoroquinolones may be less irritating and are only given twice a day. Systemic antibiotics are not indicated unless extension into the periauricular tissues is noted. Patients should avoid swimming and should prevent water from entering the ear while bathing. Dry heat aids in resolution, and analgesics provide symptomatic relief. Follow-up should be arranged in 10 days for routine cases.
Resistant cases may have an allergic or eczematous component. These typically present with a dry, scaly, itchy EAC and are chronic in nature.
Drying the EAC after water exposure with a 50:50 mixture of isopropyl alcohol and water or with acetic acid (white vinegar) minimizes recurrence. If the TM is possibly perforated, isopropyl alcohol should be avoided.
If a TM perforation is suspected and antibiotic drops are indicated, a suspension is recommended.
Consider malignant OE, typically caused by Pseudomonas aeruginosa, in elderly, diabetics, or immunocompromised patients. Exposed bone, ulceration of the EAC, and facial nerve weakness are hallmarks. Treatment for malignant OE is more intensive and focused on the presumptive organism.
Otitis Externa. A discharge is seen coming from the external auditory canal, which is swollen and almost completely occluded. An ear wick placed in the EAC facilitates delivery of topical antibiotic suspension and drainage of debris. (Photo contributor: Frank Birinyi, MD.)
Aspergillus Otitis Externa. Chronic otitis externa with copious debris, including black spores from A niger, cottony fungal elements, and wet debris. This patient had been treated with topical and systemic antibiotics. (Photo contributor: C. Bruce MacDonald, MD.)