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Acute Otitis ExternaAka: Otitis Externa, Swimmer's Ear

See Also
1. Chronic Otitis Externa
Epidemiology
1. Five times more common in swimmers than non-swimmers
2. Bilateral involvement in 10% of acute cases
3. Age peaks at 7-12 years and decreases after age 50
Pathophysiology
1. Perfect Bacterial Environment: Moist, warm canal
2. Commonly follows swimming or bathing
  1. Water in canal washes off oils and wax
    1. Results in dry, fissuring skin
    2. More susceptible to trauma
    3. Excoriation from cotton swabs
Differential Diagnosis
1. Infectious Causes
  1. Bacterial Otitis Externa (most common)
  2. Fungal Infection (Otomycosis)
    1. Causes 10% of acute otitis externa cases
    2. Causes large percentage of Chronic Otitis Externa
  3. Viral Infection
    1. Herpes simplex and Herpes Zoster (Vesicles)
2. Noninfectious causes (See Chronic Otitis Externa)
Predisposing factors
1. Moist ear canal
  1. Swimming
  2. Sweating
  3. High humidity in warm environment
2. Generalized skin conditions
3. External ear canal trauma
  1. Cotton swabs
  2. Matchsticks
  3. Hairpins
  4. Earplugs
  5. Hearing Aids
  6. Finger nails
  7. Ear plugs
Symptoms
1. Pain (85%)
  1. Skin tightly adherent to cartilage
    1. No room for inflammation
    2. Edema compresses nerve fibers against cartilage
  2. Exacerbated by chewing and other auricle movement
2. Pruritus (66%)
  1. Precedes pain in acute inflammation
  2. Predominant symptom in chronic disease
3. Otorrhea
  1. Acute Bacterial Otitis Externa
    1. Scant white mucus (may be thick)
  2. Chronic Bacterial Otitis Externa
    1. Bloody discharge with granulation tissue
  3. Fungal Otitis Externa (Otomycosis)
    1. Fluffy discharge
    2. Color: white, black, gray, blue-green or yellow
4. Conductive Hearing Loss
  1. Associated with swelling and debris in canal
5. Systemic symptoms absent
Signs
1. Otoscopy
  1. Ear canal with erythema, edema, and exudate
  2. Tympanic Membrane mobile
  3. Visualization often requires removal of Otorrhea
    1. See Ear Canal Suction
    2. Cotton-tipped swab (alternative to suction)
      1. Wisp or fluff cotton out
      2. Mops up thin watery secretions
    3. Integral part of ear toilet (see below)
2. Pain with movement of the tragus or auricle
3. Lymphadenopathy at upper neck or around auricle
Differential Diagnosis
1. Chronic Otitis Externa
2. Acute Otitis Media with perforated tympanic membrane
3. Localized Otitis Externa (Staphylococcal Folliculitis)
4. Suppurative Perichondritis
5. Malignant External Otitis
6. Chronic Otitis Media complication
Management: General
1. Ear toilet
  1. Ear Canal Suctioning for 2-3 days to remove debris
  2. Do not put anything in ear including Cotton Swabs
2. Topical Analgesic (Avoid if TM perforated)
  1. Auralgan
  2. Tetracaine
3. Cotton wick to allow medication penetration
  1. Cotton
  2. Gauze
  3. Compressed hydroxycellulose (Otowick)
4. Tympanic Membrane Perforation or unknown status
  1. Avoid most topical ear agents
  2. Avoid Flushing ear
5. Return to swimming recommendations
  1. Consider no immersion for 7 to 10 days
  2. Competitive swimmers may return in 3 days if no pain
  3. Consider wearing ear plugs
Management: Cause Specific
1. Acute Otitis Externa
  1. See Bacterial Otitis Externa (most acute cases)
  2. See Malignant Otitis Externa
  3. See Fungal Otitis Externa (only 10% of acute cases)
2. Chronic Otitis Externa
  1. See Fungal Otitis Externa
  2. See Allergic Otitis Externa
Prevention
1. To avoid getting water in ear while bathing
  1. Put vaseline coated cotton in ear to cover meatus
  2. Ear plugs
  3. Tight fitting bathing cap
  4. Special care with shampooing
2. After bathing or swimming
  1. Dry canal with hair dryer on lowest setting
3. Avoid ear trauma
  1. Avoid cotton-tipped swabs in ear
  2. Avoid scratching inside ear
4. Instill 1-2 drops of one of following qd and prn swim
  1. Otic Acetic Acid solution (with or without Alcohol)
  2. Aluminum acetate (Burow's Solution) in Star-Otic
References

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This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 5/16/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.