Otitis externa

What is otitis externa?

Otitis externa is a condition that causes inflammation (redness and swelling) of the external ear canal – the tube between the outer ear and eardrum.

Otitis externa is often referred to as "swimmer's ear", as repeated exposure to water can make the ear canal more vulnerable to inflammation (otitis externa is one of the most common conditions to affect competitive swimmers).

Symptoms of otitis externa include:

• ear pain, which can range from moderate to severe
• a discharge of liquid or pus from the ear
• some degree of temporary hearing loss

Usually only one ear is affected.

With treatment, these symptoms should clear up within two-to-three days.

In some cases the symptoms can persist for several months, which is known as chronic otitis externa. The symptoms of chronic otitis externa tend to be much milder.

Read more about the

.

What causes otitis externa?

Repeated exposure to water increases your risk of otitis externa. This is because water can clear earwax out of the external ear canal, making it very itchy. If you try to scratch inside your ear, the sensitive skin of the canal can break down, allowing an infection to take place.

Water in the ear also creates a moist environment, which encourages bacteria to grow.

Other causes include:

• a spot (pimple) developing inside the ear
• a fungal infection
• something directly irritating the ear canal, such as a hearing aid or an ear plug

Read more about the

.

Otitis externa treatment

If you think you may have otitis externa, see your doctor as it tends to last for several weeks if it is not treated.

Painkillers are used alongside eardrops to treat the underlying swelling and any infection.

In very severe cases of infection, antibiotics (that you take as a capsule, tablet or suspension that you drink), such as flucloxacillin, may be prescribed.

Read more about

.

Who is affected?

Otitis externa is relatively common. It is estimated that around 10% of the population will be affected at some point in their lives.

The condition is slightly more common in women than men (possibly because more women go swimming regularly).

People with certain long-term (chronic) conditions, such as

, or , are at greater risk of developing otitis externa.

How to prevent otitis externa

If you are a regular swimmer, consider getting a swimmer’s hat to cover your ears and protect them from water. Ear plugs are not recommended as they can cause damage to your ear canals.

Make sure that you ear canals are clear of water after swimming, bathing or showering.

Read more about

.

Complications of otitis externa

Complications of otitis externa are uncommon but some can be very serious.

A rare and potentially fatal complication of otitis externa is the infection spreading into the underlying bone – this is known as malignant otitis externa and may require surgery.

Read more about the

.

What are the symptoms of otitis externa?

Most case of otitis externa are caused by inflammation (redness and swelling) of the external ear canal and will cause the following symptoms:

• ear pain
• a feeling of pressure and fullness inside your ear
• redness and swelling of your outer ear and ear canal, which can be very painful
• scaly skin in and around your ear canal, which may peel off
• discharge from your ear, which can be either thin and watery or pus-like
• itching and irritation in and around your ear canal
• tenderness when you move your ear or jaw
• swollen and sore glands (lymph nodes) in your throat
• some hearing loss

Otitis externa can develop as the result of a hair follicle becoming infected by bacteria – this then grows into a spot (pimple) or occasionally a boil. This is known as localised otitis externa.

You may be able to see the pimple or boil by twisting your ear up towards a mirror: it will often have yellow or white pus at its centre. (Do not attempt to squeeze the pimple or boil as this could lead to infection spreading elsewhere.)

Other symptoms include:

• severe ear pain, particularly when you move your ear
• occasional hearing loss, which can occur if the pimple or boil is obstructing your ear canal
• tender and painful glands behind your ears

Long-term (chronic otitis externa)

In some cases, for reasons that are not always clear, the symptoms of otitis externa can persist for several months and in some cases, years.

This is known as chronic otitis externa, which has a different pattern of symptoms, including:

• a constant itch in and around your ear canal, which is often the main symptom
• discomfort and pain in your ear which becomes worse when you move it – the pain is usually much milder compared to other types of otitis externa
• a thin and watery discharge that comes from your ear
• a lack of ear wax
• a build-up of thick, dry skin in your ear canal, known as stenosis, which can narrow your ear canal and affect your hearing

Discharge is when a liquid such as pus oozes from a part of your body.

Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Causes of otitis externa

There are several different causes of otitis externa, as well as a number things that make it more likely to occur. These are outlined below.

Bacterial infection

Bacterial infection is a common cause of acute otitis externa. The bacteria that cause the infection are usually either Pseudomonas aeruginosa or Staphylococcus aureus. In cases of chronic otitis externa, there may be an ongoing, mild infection, which is difficult to diagnose.

Seborrhoeic dermatitis

Seborrhoeic dermatitis is a common skin condition where the areas of your skin that are naturally greasy (sebaceous), such as the side of your nose, your forehead and your scalp, become irritated and inflamed (swollen). This may contribute to the development of otitis externa.

Middle ear infection

If you have had a middle ear infection, such as

, your ear may have been producing discharge over a prolonged period of time. In some cases, the discharge may cause otitis externa.

Fungal infection

The type of fungus that can cause otitis externa includes the Aspergillus variety and the Candida albicans variety, which also causes thrush.

If you have been using antibacterial eardrops or aural corticosteroids (ear medication that relieves swelling) over a long period of time to treat another infection, you may develop a secondary fungal infection that can cause otitis externa.

Allergic and irritant reactions

Otitis externa can sometimes be caused by an allergic or irritant reaction to something that comes into contact with your ears, such as ear medication, ear plugs or shampoo. If you wear a hearing aid, you may find that it makes the inside of your ear sweaty, which sometimes can cause otitis externa.

Incomplete treatment

If you are being treated for acute otitis externa and you do not complete your treatment, you may go on to develop chronic (long-term) otitis externa.

Possible otitis externa triggers

The following things are not direct causes of otitis externa, but they may make developing the condition more likely.

Excessive moisture

You are more likely to get otitis externa if liquid gets into your ear canal. Water can wash away ear wax inside your ears making them itchy. If you scratch inside your ears, the skin can become damaged, making the external canal more vulnerable to infection.

Moisture also provides an ideal environment for bacteria (and to a lesser degree fungi) to grow. The link between exposure to water and otitis externa is why the condition is often referred to as "swimmer’s ear".

Swimming (particularly in dirty or polluted water), sweating and humid environments may increase your risk of otitis externa.

Ear damage

Your ear canal is very sensitive and can easily become damaged through scratching, excessive cleaning, ear syringing and the insertion of cotton buds. You may also damage it by incorrectly or excessively wearing hearing aids, ear plugs or ear phones.

Chemicals

Your chances of getting otitis externa are increased if you use products that contain chemicals in or near your ears, such as hair sprays, hair dyes and earwax softeners.

Underlying skin conditions

As well as seborrhoeic dermatitis being a potential risk factor for otitis externa, underlying skin conditions such as psoriasis,

and can also increase your risk of developing the condition.

Allergic conditions

If you have allergic rhinitis or asthma, you may also be at a higher risk of developing otitis externa.

Weak immune system

If you have a condition that weakens your immune system, such as diabetes,

, or if you have been having certain cancer treatments, such as , you may be at higher risk of developing otitis externa.

Inflammation Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

How is otitis externa diagnosed?

See your doctor if you think you may have otitis externa. They will ask you about your symptoms and whether you use any items that are inserted into your ears, such as hearing aids or ear plugs.

Ear examination

Your doctor may use an instrument that has a light at one end, known as an otoscope, to examine your outer ear (pinna) and your ear canal. They will check your ear for redness and inflammation (swelling).

During the examination, your doctor may also check for flaky skin, any visible sign of a fungal infection and whether or not your eardrum (tympanic membrane) is perforated (has a hole in it).

Ear swab

If you have recurring episodes of otitis externa or if medication that you have previously been prescribed hasn't worked, your doctor may take a sample from your ear using an ear swab. This will help determine whether your infection is bacterial or fungal so that the appropriate medication can be prescribed.

Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and some others are good for you.

What is the treatment for otitis externa?

There are various treatment options for otitis externa which can be broken down into three main categories:

• treatments you can use to help manage the symptoms at home
• treatments your doctor can provide
• treatments that a specialist can provide

Managing your symptoms at home

The advice below should help relieve symptoms (to a certain extent) and prevent complications.

• Avoid getting your affected ear wet. It can help to wear a shower cap while showering and bathing. Remove any discharge or debris by gently swabbing your outer ear with cotton wool, being careful not to damage it; don't stick cotton wool or a cotton bud inside your ear as this could damage it.
• Remove anything from your affected ear that may cause an allergic reaction, such as hearing aids, earplugs and earrings.
• Use painkillers, such as
  paracetamol
  or
  ibuprofen
  , to relieve ear pain. However, don't take ibuprofen if you are asthmatic or have stomach problems, such as stomach ulcers (past or present). If you're unsure whether you should take it, check with your doctor, practice nurse or pharmacist. Children under the age of 16 shouldn't take aspirin.
• Placing a warm flannel or cloth over the affected ear may also help to relieve pain.
• Avoid swimming until you are sure that the infection has passed.

Treatments your doctor can provide

While otitis externa can clear up by itself, this can take several weeks without treatment.

Your doctor can usually prescribe medicated eardrops that speed up the healing process. There are four main types of eardrops used to treat otitis externa:

• antibiotic eardrops – which can treat an underlying bacterial infection
• corticosteroid eardrops – which can help reduce swelling
• antifungal eardrops – which can treat an underlying fungal infection
• acidic eardrops – the acid can help kill bacteria

Sometimes you may be given medication that's a combination of the above, such as antibiotic and corticosteroid eardrops.

Applying eardrops

Ear drops may not work as well if they are not used in the right way so it's important to apply them correctly. Ideally, ask somebody else to apply the drops for you as this makes the process much easier.

You (or your helper) will need to follow these steps:

• Gently remove any discharge, ear wax or debris from your outer ear and ear canal using a twist of cotton wool (do not use a cotton bud).
• Warm the eardrops by holding them in your hands for a few minutes – cold eardrops can make you feel dizzy.
• Lie on your side with your affected ear facing up before applying the drops directly into your external ear canal and then gently push and pull your ear to work the drops in and to get any trapped air out.
• Stay lying down for 3-5 minutes to ensure that the eardrops do not come out of your ear canal.
• Leave the ear canal open to dry.

Other treatments

Other treatments your doctor can provide include:

• stronger prescription painkillers such as codeine for severe cases
• antibiotics tablets or capsules to treat a severe infection – an antibiotic called flucloxacillin is usually the preferred choice
• treatment for underlying skin conditions that may aggravate your otitis externa, such as seborrhoeic dermatitis, psoriasis or eczema
• if a boil develops inside your ear your doctor may decide to pierce it with a sterile needle and drain the pus; this is known as incision and drainage (never attempt to do this yourself)

Specialist treatment

You may be referred to a specialist if your symptoms are severe or they fail to respond to treatment.

One option is to remove earwax from inside your ears to help make eardrops more effective. This can be done in a number of ways, such as:

• syringing or irrigation, where water is injected through the nozzle of a syringe into the ear canal to dislodge and wash away any ear wax
• microsuction, where a small suction device is used to remove any ear wax, discharge and debris from your outer ear (pinna) and ear canal
• dry swabbing to gently mop out any ear wax from your ear canal

You may also need an ear wick, which is a soft cotton gauze plug covered with medication and inserted into your ear canal.

An ear wick allows the medication to reach the end of your ear canal. It should be changed every two or three days.

Antibiotics are medicines that can be used to treat infections caused by micro-organisms, usually bacteria or fungi. Examples of antibiotics include amoxicillin, streptomycin and erythromycin.

Discharge is when a liquid such as pus oozes from a part of your body.

Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.

Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

How to prevent otitis externa

You can take several steps to avoid otitis externa and prevent it from recurring. These are described below.

Avoid damaging your ears

• Don't insert cotton wool buds or other objects into your ears. Wax works its way out naturally and cotton buds should only be used to sweep around your outer ear (pinna).
• If earwax build-up is a problem, have it removed by a healthcare professional.

Keep your ears dry and clean

• Don't let water, soap or shampoo get inside your ears when you wash them. Wear a shower cap while you shower or bathe.
• After washing, dry your ears using a hairdryer on a low setting. Never push the corners of a towel into your ears to dry them because this can cause damage.
• If you swim regularly, wear a swimming hat that covers your ears or use ear plugs.

Treat and prevent other skin conditions

• If you develop otitis externa and you have an allergic disposition (a tendency to get allergies), tell your doctor or practice nurse. Eardrops that contain certain substances, such as neomycin or propylene glycol, are more likely to cause an allergic reaction than others. Your doctor, practice nurse or pharmacist can advise you about which eardrops are most suitable for you.
• If you have an allergic reaction to anything that is placed inside your ears, such as hearing aids, earplugs or earrings, remove the item. A mild allergic reaction will usually clear up on its own. Using hypoallergenic products (products that have a lower potential for causing allergic reactions) may also help.
• Seek medical advice for any other skin conditions, such as psoriasis or eczema, so they can be treated using the right medication.
• Try using acidifying eardrops or spray to help keep your ears clean, particularly before and after swimming. They may help prevent otitis externa recurring, and are available without a prescription in most pharmacies.

Can otitis externa cause other problems?

Complications associated with otitis externa are usually uncommon. However, the the following complications can sometimes occur.

Abscesses

are usually painful, pus-filled growths that can form in and around the affected ear after an infection. They usually heal on their own but, in some cases, your doctor may need to drain the pus from them.

Stenosis of the ear canal

Stenosis is the name given to the build-up of thick, dry skin in your ear canal, which can occur if you have the condition chronic otitis externa.

It can affect your hearing because the build-up of skin makes your ear canal narrower. In rare cases, it can cause deafness. Stenosis of the ear canal can be treated using eardrops.

Inflamed or perforated eardrum

It is possible for any infection to spread to your eardrum.

In some cases, the infection may cause pus to build up inside your inner ear and may rupture (tear) your eardrum. This is know as a

.

Symptoms include:

• temporary hearing loss
• earache or discomfort
• a discharge of mucus from your ear
• ringing or buzzing in your ear (tinnitus)

In many cases a perforated eardrum will heal without treatment in around two months. If it shows no signs of healing after this time then surgery may be recommended.

Cellulitis

is a bacterial skin infection that can occur after otitis externa. It's when bacteria, which normally live harmlessly on the surface of your skin, enter your skin's deeper layers through damaged areas, such as those caused by otitis externa.

Cellulitis causes affected areas of skin to become red, painful, hot and tender to the touch.

Other symptoms include:

• feeling sick
• shivering
• chills
• a general sense of feeling unwell

Most cases of cellulitis can be treated with a seven-day course of antibiotics.

If cellulitis occurs in a person who was already very ill or who is very vulnerable to the effects of infection, they may need to be admitted to hospital as a precaution.

Malignant otitis externa

Malignant otitis externa is a serious but very rare complication of otitis externa, in which the infection spreads to the bone that surrounds your ear canal.

Malignant otitis externa usually affects adults more than children. In particular, adults who are immunocompromised (have a weakened immune system) have an increased risk of developing it. This includes people having chemotherapy treatment or who have a chronic (long-term) health condition, such as diabetes, HIV or AIDS.

If you have malignant otitis externa, you may have one or more of the following symptoms:

• severe ear pain and headaches
• exposed bone visible in your ear canal
• facial nerve palsy, where your face droops on the side of the affected ear

Without treatment, malignant otitis externa can be fatal. However, it can be effectively treated using antibiotics and surgery to remove any damaged tissue.