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Acute Otitis Externa
Aka: Acute Otitis Externa, Otitis Externa, Swimmer's Ear- See Also
- Definitions
- Otitis Externa
- Diffuse inflammation of the External Ear canal
- Otitis Externa
- Epidemiology
- Five times more common in swimmers than non-swimmers
- Bilateral involvement in 10% of acute cases
- Age peaks at 7-12 years and decreases after age 50 years
- Most common in summer
- Pathophysiology
- Causes
- Infectious Causes
- Bacterial Otitis Externa (most common)
- Staphylococcus aureus
- Pseudomonas aeruginosa
- Polymicrobial (one third of cases)
- Fungal Infection (Otomycosis)
- Causes 10% of Acute Otitis Externa cases
- Causes large percentage of Chronic Otitis Externa
- Viral Infection
- Herpes simplex and Herpes Zoster
- Ramsay Hunt Syndrome (herpetic Vesicles in ear canal)
- Herpes simplex and Herpes Zoster
- Bacterial Otitis Externa (most common)
- Noninfectious causes (See Chronic Otitis Externa)
- Infectious Causes
- Risk factors
- Moist ear canal
- Swimming
- Sweating
- High humidity in warm environment
- Generalized skin conditions
- Ear canal obstruction
- Canal stenosis or exostosis
- Cerumen Impaction
- Excessive ear canal hair
- Ear Foreign Body
- Sebaceous Cyst
- External Ear canal Trauma
- Earphones
- Cotton swabs
- Matchsticks
- Hairpins
- Earplugs
- Hearing Aids
- Finger nails
- Ear plugs
- Prior Radiation Therapy to region (associated with higher compliocation risk)
- Moist ear canal
- Symptoms
- Pain (85%)
- Skin tightly adherent to cartilage
- No room for inflammation
- Edema compresses nerve fibers against cartilage
- Exacerbated by chewing and other auricle movement
- Skin tightly adherent to cartilage
- Pruritus (66%)
- Precedes pain in acute inflammation
- Predominant symptom in chronic disease
- Otorrhea
- Acute Bacterial Otitis Externa
- Scant white mucus (may be thick)
- Chronic Bacterial Otitis Externa
- Bloody discharge with granulation tissue
- Fungal Otitis Externa (Otomycosis)
- Fluffy discharge
- Color: white, black, gray, blue-green or yellow
- Acute Bacterial Otitis Externa
- Conductive Hearing Loss
- Associated with swelling and debris in canal
- Systemic symptoms absent
- Pain (85%)
- Signs
- Otoscopy
- Ear canal with erythema, edema, and exudate
- Tympanic Membrane mobile
- Visualization often requires removal of Otorrhea
- See Ear Canal Suction
- Cotton-tipped swab (alternative to suction)
- Wisp or fluff cotton out
- Mops up thin watery secretions
- Integral part of ear toilet (see below)
- Pain with movement of the tragus or auricle
- Lymphadenopathy at upper neck or around auricle
- Otoscopy
- Red Flags
- Findings suggestive of infectious spread beyond the ear canal
- Fever over 101
- Severe Otalgia
- Lymphadenopathy
- Trismus
- Cranial Nerve palsy (especially Facial Nerve)
- Patient risk factors associated with Malignant Otitis Externa
- Older patients with Diabetes Mellitus
- Immunocompromised patients
- Findings suggestive of infectious spread beyond the ear canal
- Differential Diagnosis
- Management: General
- Ear toilet
- Ear Canal Suctioning for 2-3 days to remove debris
- Do not put anything in ear including Cotton Swabs
- Topical Analgesic
- Precautions
- Avoid if Tympanic Membrane perforated
- May decrease effectiveness of other Topical Medications
- Consider using systemic Analgesics instead (e.g. NSAIDS)
- Agents
- Auralgan
- Tetracaine
- Precautions
- Cotton wick to allow medication penetration
- Cotton
- Gauze
- Compressed hydroxycellulose (Otowick)
- Tympanic Membrane Perforation or unknown status
- Avoid most topical ear agents (limit to specifically known safe topical agents)
- Avoid Flushing ear
- Return to swimming recommendations
- Consider no immersion for 7 to 10 days
- Competitive swimmers may return in 3 days if no pain
- Consider wearing ear plugs
- Ear toilet
- Management: Cause Specific
- See Ear Canal Instillation for topical otic medication instillation
- Acute Otitis Externa
- See Bacterial Otitis Externa (most acute cases)
- See Malignant Otitis Externa
- See Fungal Otitis Externa (only 10% of acute cases)
- Chronic Otitis Externa
- Prevention
- To avoid getting water in ear while bathing
- Put vaseline coated cotton in ear to cover meatus
- Ear plugs
- Tight fitting bathing cap
- Special care with Shampooing
- After bathing or swimming
- Dry canal with hair dryer on lowest setting
- Avoid ear Trauma
- Avoid cotton-tipped swabs in ear
- Avoid scratching inside ear
- Instill 1-2 drops of one of following qd and prn swim
- White vinegar (or Otic Acetic Acid) 1/3 in Rubbing Alcohol 2/3 OR
- Aluminum acetate (Burow's Solution) in Star-Otic
- To avoid getting water in ear while bathing
- Complications
- Resources
- References
- Beers (2004) Pediatr Emerg Care 20:250-6 [PubMed]
- Bojrab (1996) Otolaryngol Clin North Am 29:761-82 [PubMed]
- Dohar (2003) Pediatr Infect Dis J 22:299-305 [PubMed]
- Halpern (1999) J Am Board Fam Pract 12(1):1-7 [PubMed]
- Mirza (1996) Postgrad Med 99:153-8 [PubMed]
- Osguthorpe (2006) Am Fam Physician 74:1510-6 [PubMed]
- Rosenfeld (2006) Otolaryngol Head Neck Surg 134 (4 suppl): S4-23 [PubMed]
- Sander (2001) Am Fam Physician 63:927-42 [PubMed]
- Schaefer (2012) Am Fam Physician 86(11): 1055-61 [PubMed]