OTITIS EXTERNA Uncovered: Causes, Types, and Treatment of the Most Painful Ear Condition

Ear Problems in COVID-19


Otitis externa (OE) is an intense inflammation of the External auditory Canal


  • Most common microorganism: Pseudomonas aeruginosa
  • Other common organisms: Staphylococcus aureus and Staphylococcus epidermidis
  • Uncommon microorganisms: Coryneform (diphtheroids), Gram-negative rods (Enterobacter Klebsiella, Proteus, Escherichia coli), Streptococcus and Enterococcus.

Actinomyces israelii is an anaerobic Gram-positive bacterium that can cause OE from primary dental or parotid infection.

Refractory OE presents with granulation tissue in EAC and thick yellow ear discharge and needs surgical debridement and prolonged antibiotic therapy.

Cultures for bacteria and fungus are indicated in persistent or refractory infection.

Acute Otitis Externa

Excessive and repeated removal of the hydrophobic earwax coating of EAC exposes the underlying epithelium to water, infection, and other contaminants and leads to progressive erythema and edema.

Predisposing factors

1) Warm humid environment:

Excessive sweating changes the canal pH to alkaline, which favors bacterial growth.


2) Obstruction of EAC:

Stenosis, exostoses, impacted wax are major contributing factors for OE.

3) Ear trauma:

Use of cotton-tip swabs, irrigators for wax removal, in-the-canal hearing aids, digital ear thermometers, unskilled instrumentation.

4) Water contamination of EAC:

It is usually swimming related.

Hence, acute otitis externa is also very commonly known as the SWIMMER’s EAR.

Clinical features


It is the chief presenting complaint.

Ear pain may be aggravated with jaw movements like chewing, opening mouth, etc.

ear pain


It is usually watery-like means serous.

3) Itching

It is present in some cases.


Early stage: An erythematous canal with scant discharge

Later on: Edematous and exquisitely tender canal occluded with purulent squamous debris

In severe cases: Enlarged and tender regional lymph nodes and periauricular cellulitis

No additional systemic sign and symptoms

Treatment of Otitis Externa

1) Cleaning of EAC

This clears the infected debris material and allows topical antibiotics to reach the infected site.

2) Acidification of EAC

Acetic acid solution and antibiotics in acidic suspensions and solutions kills many bacteria and fungus.

3) Topical Antibiotics

Topical Antibiotics ear drops provide a concentration many times greater than systemic antibiotics in the ear canal. Thus usually it is not necessary to start systemic antibiotics even in resistant infection.

Quinolone antibiotic drops (ofloxacin, ciprofloxacin) with dexamethasone (hydrocortisone is avoided as it leaves a precipitate) in an acidic vehicle are the best as they have no ototoxicity and no potential for allergic reactions.

Antibiotic impregnated ear wicks (cotton, merocel, ribbon gauze) offer better absorption through an edematous canal skin.

4) Oral antibiotics

These are reserved for complications of OE such as cellulitis, perichondritis, chondritis and malignant OE.

Chronic Otitis Externa

No prior history of trauma or water contamination

Usually not painful

Examination may reveal FUNGAL HYPHAE in the canal or keratin debris from chronic dermatitis.

Acute exacerbation is usually preceded by itching.

Types of Chronic OE

The four different disease states with distinct etiologies are allergic, contact dermatitis, seborrhea and granular OE.

1) Allergic OE

Clinical features:

  • Edema and purulent discharge secondary to topical antibiotic (most commonly neomycin) ointment or drops.
  • Maculopapular eruption in concha and EAC.
  • A thickened and erythematous canal.

Treatment of Allergic OE:

– Elimination of offending agent, debridement and topical steroid drops.

2) Contact Dermatitis

Clinical features:

  • It can result from a variety of agents, such as hairsprays, shampoos and hearing aid molds.
  • A thickened and erythematous canal.

Treatment of Contact Dermatitis:

–Elimination of offending agent.

– Debridement and topical steroid drops.

3. Psoriasis or Seborrhea

Clinical features:

  • Hyperkeratosis and lichenification of EAC skin.
  • Seborrheic OE is associated with seborrheic dermatitis of the scalp.
  • Itching is the presenting complaint.
  • Greasy yellow scales may be seen in the canal, over the lobule and in postauricular sulcus.
  • Secondary bacterial or fungal infections may occur.

Treatment of Seborrheic OE:

– Treatment of scalp seborrhea.

– Ear toilet, salicylic acid, and sulphur cream

4. Granular OE

Clinical features:

  • It results from chronic bacterial or fungal infection of EAC.
  • Granulation and excoriation seen on TM and EAC skin.
  • Culture for bacteria and fungus may show causative organisms.

Treatment of Granular OE-

– Repeated debridement.

– Cauterization of granulations.

– Topical antibiotic or antifungal creams.

– Topical gentian violet facilitates at drying the EAC.

– Topical steroid or 5-fluorouracil.

– De-epithelialization of TM: If does not respond to drying agent (Burow’s solution) it may need spilt thickness skin graft.

Complications of OTITIS EXTERNA

1) Cellulitis:

It present as an erythematous ear. There is no induration like perichondritis.

Treatment is with systemic antistaphylococcal agent.

2) Perichondritis or Chondritis

3) Medial canal fibrosis:

In chronic otitis externa (COE), thick fibrous scar may obstruct deep aspect of EAC.

TM appears lateralized with absence of typical landmarks.

Surgical treatment consists of excision of the fibrous scar followed by canaloplasty with split thickness skin graft and if needed tympanoplasty

4) Malignant otitis externa

A very severe LIFE THREATENING form of Otitis Externa.



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The Author does not provide any medical advice on this platform.

Viewing, accessing, or reading this blog does not establish any doctor-patient relationship.

The information provided in this blog does not replace the services and opinions of a qualified medical professional who examines you and then prescribes medicines.

And if you have any questions of medical nature, please refer to your doctor or qualified medical personnel for evaluation and management at a clinic/hospital near you.

The content provided in this blog represents the Author’s own interpretation of research articles.

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