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Non-infectious
external ear
conditions
Otitis externa
Managing acute
otitis externa
Other
conditions of
the external ear
The author
External
EAR CONDITIONS
DR MICHAEL A TAPLIN,
Ear, nose and throat surgeon
(adult and paediatric), VMO
Sydney Children’s Hospital,
Randwick; Mater Misericordiae
Hospital, North Sydney; Hunters
Hill Private Hospital; and Prince
of Wales Private Hospital,
Randwick, NSW.
Background
INCREASED time in the water and
humidity during the summer months
favour bacterial and fungal infections of the ear, which are usually
easily diagnosed and treated in the
GP setting.
Recent concern regarding bacterial resistance and medication ototoxicity have led to the development of sound guidelines for
appropriate, safe and efficacious
treatments.
Anatomy and physiology
The external ear is composed of the
auricle (pinna), external auditory
meatus (canal) and the lateral
(epithelialised) surface of the tympanic membrane.
The pinna acts to amplify and
localise sound, as well as protecting
the ear canal and the deeper structures (tympanic membrane, ossicular chain, middle-ear cleft and inner
ear). The auricular cartilage deter-
mines the pinna’s shape and is continuous with the cartilaginous portion of the lateral one-third of the
ear canal. The prominent position
of the pinna renders it susceptible to
trauma.
The external auditory canal is
angulated (figure 1, page 27) and
divided into cartilaginous (lateral
one-third) and bony (medial twothirds) portions. The cartilaginous
portion has loosely bound, thicker
skin containing hairs, with numerous sebaceous and ceruminous
(wax-producing) glands.
In the bony portion the subepithelial layer of the skin is minimal and
the skin is tightly adherent to the
underlying periosteum. The skin in
the deep ear canal does not produce
wax and is particularly sensitive and
susceptible to trauma.
The epithelium of the lateral tymcont’d page 27
1-3
Before prescribing please review approved Product Information and PBS information found in the primary advertisment in this publication.
Full PI available from Novartis Pharmaceuticals Australia Pty Ltd, 54 Waterloo Road, North Ryde NSW 2113.
References: 1. Prexige (lumiracoxib) Australian Product Information. 2. Tannenbaum H, et al. Ann Rheum Dis. 2004;63:1419-1426. 3. Fleishmann R et al. Clin Rheumatol. 2005;25:42-53.
NOVPRE0204/PRX236807
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13 April 2007 | Australian Doctor |
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from page 25
panic membrane and ear
canal has a unique selfcleansing mechanism. The
skin migrates laterally, similar to a conveyor belt,
towards the conchal bowl,
where wax and keratin are
shed. Failure to migrate
leads to keratin and wax
obstruction.
Lymphatic
drainage
extends anteriorly to the preauricular and parotid nodes,
posteriorly to the mastoid
nodes and inferiorly to the
cervical chain.
The external ear is innervated by the cervical plexus
(greater auricular nerve) as
well as cranial nerves V, VII,
IX and X (trigeminal, facial,
glossopharyngeal
and
vagus). As a result, instrumentation of the ear canal
may lead to throat tickle and
cough, and throat or
oropharyngeal pain can be
referred to the ear (referred
otalgia).
Figure 2: Cerumen impaction.
Figure 1 A: Normal ear canal. B: Marked angulation of the bony
ear canal (coronal CT, petrous temporal bones).
A
B
midis is the most common
commensal
organism.
Pseudomonas aeruginosa
and Staphylococcus aureus
are the most common
pathogens found in infected
ears.
Cerumen and wax
Table 1: Microbiology of the healthy and infected ear
Micro-organism
Staphylococcus epidermidis
Corynebacterium/diphtheroids
Alpha-haemolytic streptococci
Staphylococcus aureus
Anaerobes (Escherichia coli, Proteus)
Klebsiella, Enterobacter
Pseudomonas aeruginosa
Healthy ear
(% of normal flora)
33-100%
<33%
<33%
<33%
<33%
<5%
<5%
Aspergillus, Candida
<5%
Microbiology (table 1)
The normal flora of the ear
canal is similar to that of
Otitis externa
(% of normal flora)
<5%
<5%
<5%
<33%
Unknown
<33%
33-100% (more common
in swimmers)
0-66% (more common
in tropical climates )
the skin. Water exposure
and excessive cleaning of
the canal will alter the
microbiological balance of
the external ear.
Staphylococcus epider-
Ceruminous glands are
modified sweat glands.
Secretions from the sebaceous and ceruminous
glands, together with
desquamated epithelial cells
and hairs, constitutes ‘wet’
wax. This is usually golden
brown or ochre in colour
and sticky. It is found more
commonly in Caucasians
and dark-skinned populations.
‘Dry’ wax is hard and
darker in colour. There is
usually a greater amount of
compacted keratin squames
and it easily forms a ball
that may impact (figure 2).
‘Oriental’ wax, or ‘rice
bran’ wax, is typically
found in Asian races. It is
dry, golden yellow and very
flaky.
Wax comprises lipid,
protein and free amino
acids as well as lysozymes
and immunoglobulins.
Together with an intact
skin epithelium, it provides
a sound immunological
barrier.
An acidic pH (4-5) discourages bacterial and
fungal pathogens. People
with diabetes tend to have
significantly less-acidic wax
(pH up to 8), and are thus
more prone to recurrent
and potentially serious
infections.
The average wax production is 2.81mg/week. There
is no age or gender difference. The presence of
wax is a sign of ear canal
health, despite patients’
concerns at its presence or
perceived excess. An
infected ear produces little
wax.
Non-infectious external ear conditions
Wax impaction and
cerumenolytics (table 2)
WAX impaction occurs in about 5%
of the normal population. Studies
have shown a greater prevalence in
nursing-home and institutionalised
patients (up to 30%).
Patients who regularly use cotton
buds (Q tips) to clean their ears,
often push cerumen medially on to
the tympanic membrane. This can
lead to a conductive hearing loss.
Cotton buds can lacerate the ear
canal skin, breaking the normal
immune barrier. This may lead to
canal haematoma and otitis externa.
ENT surgeons will often remove
wax and keratin with the aid of a
microscope. Wax curettes and
gentle suction ear toilet is generally well tolerated and safe.
Patients with tight stenotic ear
canals or other ear disease such as
tympanic membrane perforation
should be reviewed by a specialist
for aural toilet and further management.
Ear syringing
Ear syringing is often an effective
measure for removing simple wax.
This should only be performed by
experienced doctors. Ideally the
wax is initially loosened with the
aid of a cerumenolytic. Syringing
is contraindicated when there is
gross wax impaction in the deep
ear canal or when tympanic membrane perforation cannot be
excluded.
Syringing should also be avoided
in patients with external ear canal
infections, dermatitis of the ear
canal, previous ear surgery and in
patients with stenotic ear canals.
Complications of ear syringing
include perforation of the tympanic
membrane, laceration to the ear
canal skin and secondary otitis
externa.
Ear candles
Ear candles are not recommended.
Obstruction of the ear canal with
paraffin and associated hearing loss
and perforation of the tympanic
membrane have been reported.
Figure 3 A: Keratosis obturans. B: Keratosis obturans has expanded the
tympanic bone on the left.
A
B
Table 2: Preparations for wax removal
Preparation
Constituents
Cerumol
Chlorbutol, orthoTM perforation
dichlorobenzene,
para-dichlorobenzene,
arachis oil
Benzocaine, phenazone, TM perforation
hydroxyquinoline
sulfate, glycerol
Carbamide peroxide
TM perforation,
otitis externa
Auralgin Otic
Ear Clear for
Ear Wax
Removal
Waxsol
Docusate sodium
Hydrogen
Hydrogen peroxide
peroxide (H2O2)
Sodium
Sodium bicarbonate
bicarbonate
Olive oil
Olive oil (pure)
Distilled water
Figure 4: Microforceps for removing
wax and foreign bodies.
Water
Precaution
Action (relative
strength +)
Lubricates
cerumen plug
rather than
breaking down (+)
Lubricates
wax, local
anaesthetic (+)
Aqueous, softens
and loosens
wax (++)
Breaks down
wax (+++)
Softens and
loosens wax (++)
Breaks down
wax (++)
Lubricates wax,
ear canal
Breaks down
wax (+)
Figure 5 A: Large exostoses with
near complete canal occlusion.
B: Moderate-size exostoses.
C: Isolated osteoma at the
bony-cartilaginous junction.
A
Osteoma and exostoses of the
external ear canal
Foreign bodies in the lateral ear canal
are often easily visible and removed.
Those in the deep ear canal are often
wedged, and attempts at removal
may cause significant pain and
trauma to the ear canal and tympanic membrane.
Blunt instruments such as microforceps are often best (figure 4). It is
important to have good illumination.
A light source mounted to a glasses
frame is ideal. Resting part of the
Osteomata of the ear canal are
benign tumours. They are typically
pedunculated and solitary, arising
from the bony-cartilaginous junction
of the external ear canal. Often
found in the antero-superior portion,
they rarely cause symptoms. Large
tumours may obstruct the ear canal
and cause conductive hearing loss
(figure 5).
Exostoses originate from the
periosteum. Exposure to cold water
causes a ‘refrigeration periosteitis’.
The initial cold-induced vasoconstriction is followed by reactive
hyperaemia. Low-grade inflammation then leads to a greater degree of
bone deposition. The mature bone is
arranged in layers, giving the histological ‘onion skin’ picture.
Exostoses are often multiple and
found in the deeper portion of the ear
canal. They may contact the lateral
surface of the tympanic membrane.
Exostoses are common in Australia, especially in keen swimmers
and surfers. In the early stages,
exostoses are asymptomatic. However, with further growth there can
be obstruction of wax and keratin.
Water trapping predisposes to ear
canal infection. Hearing loss and
recurrent infections may require
surgical removal.
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13 April 2007 | Australian Doctor |
TM perforation
TM perforation
TM perforation
TM perforation,
infection
Otitis media,
TM perforation
B
TM = tympanic membrane
Keratosis obturans
Keratosis obturans is an accumulation of keratin debris that forms a
pearly white plug in the ear canal
(figure 3). The precise aetiology is
unknown but it is thought an
increased rate of desquamation and
poor epithelial migration are the
cause. It is more common in younger
people.
Over time the keratin plug exerts
pressure on the deep bony ear canal,
leading to slow bone resorption. In
extreme cases the keratin plug may
erode into the mastoid bone.
Keratosis obturans is best
removed by a specialist. The ear
canal may be very sensitive and the
hand on the patient’s face will help
stabilise hand movements and protect from inadvertent trauma associated with rapid head movements.
Children are best treated by experienced clinicians or specialists. Occasionally an anaesthetic may be
required. Live insects such as cockroaches cause particular patient distress, from fluttering and scratching
movements. Rarely drum rupture
may occur. Insects can be drowned
with olive oil or flushed out with
sterile water.
Ticks are a particular hazard. They
are often very small and easily
missed. Severe ear pain with tympanic membrane inflammation
(myringitis) and rupture can occur if
the tick is not removed promptly.
underlying skin inflamed or granulomatous. Ototopical antibiotics
may be required, followed by a
period of close surveillance.
Foreign bodies in the ear canal
C
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How to treat – external ear conditions
Otitis externa
OTITIS externa is an inflammatory condition of the ear
canal skin. The causes are
infective or non-infective
(inflammatory) (table 3).
A healthy intact skin layer
provides an effective physical
and chemical barrier to bacteria and fungi. Changes to
the micro-environment, such
as repeated trauma, exposure
to water or humidity and dermatitis, predispose to infective otitis externa. Changes to
the pH appear to be the most
significant predisposing factor
to the development of bacterial otitis externa. Risk factors
for otitis externa are summarised in table 4.
Figure 6 A: Aspergillus niger otomycosis. B: Candida albicans
otomycosis.
A
B
Bacterial
Fungal
Viral
Necrotising
(bacterial/fungal)
Non-infective Dermatitis
(inflammatory)
Seborrhoeic dermatitis
Atopic dermatitis
Atopic dermatitis often presents with itchiness, crusting,
fissuring and oozing. As with
allergic rhinitis, conjunctivitis
and asthma, there is often a
strong family history. Patients
with atopic dermatitis are
prone to develop secondary
staphylococcal infection or
viral superinfection (herpes,
vaccinia, molluscum contagiosum).
Topical neomycin has been
shown to cause contact sensitivity in 5-15% of patients.
Patch testing suggests an even
higher rate. Neomycin is a
broad-spectrum aminoglycoside antibiotic contained in
Kenacomb preparations. It is
particularly effective against
Gram-negative bacteria, but
not Pseudomonas aeruginosa.
Cosmetics, soaps, detergents, shampoos, hair sprays,
hair dyes and preservatives
can cause hypersensitivity.
Nickel, silver, rubber and
28
Dosing
Three drops
bd for
10 days
Adverse reaction
Burning
(polyethylene
glycol)
Advantages
Effective
antifungal. Some
antibacterial action
Kenacomb Otic
Three drops tds Stinging, neomycin Covers bacteria
allergy, ototoxicity and fungus
Ear Clear for
Swimmers Ear
(acetic acid in
isopropyl alcohol)
Aquaear (acetic
acid in isopropyl
alcohol)
Four drops
each ear after
swimming
Stinging
Four drops
after water
exposure
Stinging
Table 3: Classification of otitis externa
Infective
Non-infective otitis externa
— dermatological
conditions
Seborrhoeic dermatitis is
found in oil-rich areas of the
skin, especially in and
between the eyebrows,
around the base of the nose
and behind the ears. The skin
of the conchal bowl and ear
canal is itchy, dry and flaky.
Seborrhoeic dermatitis is associated with the yeast
Malassezia furfur.
Antifungal creams and
ointments such as Canesten
and Nizoral may be useful.
Topical steroid such as
mometasone (Elocon) lotion
are also effective. A once- or
twice-weekly application of a
steroid achieves some degree
of prophylaxis. The anti-dandruff shampoos are also
good, particularly if there is
scalp involvement.
Patients should avoid the
temptation to scratch the ear
or insert paper clips, pins and
cotton buds, as these will further traumatise the skin and
predispose to secondary bacterial infection. After swimming and hair washing, gentle
use of the hair dryer on a low
setting will help dry out the
ear canal.
Table 5: Ototopical therapy for otomycosis
Ototopical
LocacortenVioform
Acute diffuse
Acute localised (furunculosis)
Chronic
Otomycosis
Herpes zoster oticus
‘Malignant’
Seborrhoeic
Atopic-eczematous, iatrogenic
Psoriasis
Table 4: Predisposing factors for otitis externa
Predisposing factor
Water exposure
Wax
Dermatological
Trauma
Anatomical
Localised
ear disease
Systemic disease
Radiotherapy
Assistive hearing
devices
Examples
Seasonal humidity (‘tropical ear’),
swimming, water sports
Impaction, removal or loss of
physical protection, change of pH
Eczema, seborrhoeic, psoriasis
Foreign bodies, cotton buds,
paper clips, safety pins
Narrow/long/hairy ear canals,
stenosis, exostoses
Tympanic membrane perforation
discharge, cholesteatoma
Diabetes, immunocompromised
Head and neck, CNS malignancy
Hearing aids, ear plugs, diving
suits, mobile phone ear pieces
Figure 7: Staphylococcal
furunculosis.
plastics used in ear pieces and
hearing aids may also act as
an irritant. Nickel is the most
common contact allergen,
affecting about 10% of
people with pierced ears.
Psoriasis and discoid lupus
also have ear-canal manifestations
Viral otitis externa
Herpes zoster oticus (Ramsay
Hunt syndrome) is the most
frequent viral infection of the
external ear. The virus lies
dormant in the geniculate
ganglion (facial nerve) with
characteristic vesicular eruption involving the skin of the
external ear. This is easiest to
detect in the conchal bowl.
Initially the patient may
complain of a hot burning
sensation within the ear that
rapidly develops into severe
pain. Mastoid pain is also
very common and often precedes a facial palsy. The
recovery of full facial function
is usually less than in iatrogenic facial palsy (Bell’s
palsy).
| Australian Doctor | 13 April 2007
Figure 8: Diffuse otitis
externa (note canal oedema).
Loss of taste over the anterior two-thirds of the tongue
and decreased lacrimation
may occur on the infected
side when the chorda tympani
nerve, a branch of the facial
nerve is involved.
Hearing loss, tinnitus or
vertigo indicate inner-ear
involvement.
Vesicles on the soft palate
indicate glossopharyngeal
involvement.
Antivirals (such as, valaciclovir or famciclovir) with or
without oral steroids are indicated for facial nerve involvement. Warm compresses and
analgesia act as supportive
therapy.
Incomplete eyelid closure
requires extreme vigilance to
prevent exposure keratitis and
possible long-term visual
impairment. Consultation
with an ophthalmologist
might be necessary.
Fungal otitis externa
(otomycosis)
Fungal species colonise the
healthy ear, growing on
VoSol (propylene Five drops tds
glycol diacetate) (treatment for
swimmer’s ear)
Two drops bd
for prophylaxis
Stinging
Acid pH prevents
fungus and
bacteria. Drying
agent
Low pH prevents
bacteria and
fungus
Prevention of
and bacterial OE
Disadvantages
Viscous and yellow.
Often difficult to
administer drop.
Precaution with TM
perforation
Viscous. Potentially
ototoxic. Neomycin
sensitivity. Difficult
to administer drop.
Contraindicated with
TM perforation
Poor compliance
due to stinging. Not
to be used with
TM perforation
Poor compliance
due to stinging.
Contraindicated with
dermatitis or TM
perforation
Poor compliance
due to stinging.
Contraindicated with
TM perforation
TM = tympanic membrane
desquamated keratin and
wax. Species such as Candida
albicans and Aspergillus niger
or Aspergillus flavus can
become pathogenic, especially in patients with dermatitis. Warm, humid and
wet conditions favour their
growth.
Fungal otitis externa may
also occur after an episode
of bacterial otitis externa has
been successfully treated
with ototopical antibiotic
drops. Patients taking drops
long term are susceptible, as
the normal flora of the ear
canal is removed.
Symptoms of otomycosis
include itching, local irritation and persistent otorrhoea. Some patients complain of a “squelching”
sensation and minor pain.
Severe pain is less common.
Occasionally a patient may
be completely asymptomatic.
In the early stages of
Aspergillus otitis externa,
debris may resemble cotton
wool or a white plug. Tiny
grey-black conidiophores are
often seen with A niger
(figure 6A). In severe cases
there may be ulceration of
the ear canal and erosion or
rupture of the tympanic
membrane.
Extensive white ‘blotting
paper’ debris is typical of
Candida species (figure 6B).
Keratin debris appears very
similar and sometimes a
swab might need to be taken
for fungal culture to confirm
infection. Sprouting hyphae
are often seen with the aid
of the otological microscope.
Treatment success relies
on accurate diagnosis and
thorough aural toilet.
Removal of fungal debris
with a small curette, cotton
wool brooch or suction is
best. Syringing with water
provides fungal colonies
with ideal conditions for
proliferation and should be
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avoided. Aural toilet is
sometimes needed every
second or third day to prevent rapid re-accumulation.
Topical antifungal creams
such as clotrimazole (Canesten), miconazole (Daktarin)
and bifonazole (Mycospor)
can be placed around the circumference of the ear canal or,
more simply, placed to fill the
ear canal.
Ototopical antifungal
drops (table 5) are also effective. After aural toilet, I
prefer Locacorten-Vioform
drops, which contain the
steroid flumethasone and the
sound fungicidal clioquinol,
as well as being bacteriostatic against Gram-positive
bacteria and moderately
inhibitory against Gram-negative bacteria.
Kenacomb drops contain
nystatin, which is effective
against C albicans. The
other constituents are
neomycin (for Gram-negatives), gramicidin (for Grampositives) and the steroid triamcinolone.
Neither antifungal drop
should be used with a tympanic membrane perforation.
Long-term prevention of
otomycosis involves treating
underlying dermatitis and
avoiding water. Drying
agents containing acetic acid
with or without alcohol are
good, but contraindicated
with a tympanic membrane
perforation and when there
is a break in the skin, as they
may cause severe pain.
Fungal otitis externa is
treated aggressively in the
elderly or immunocompromised host as infection
beyond the ear canal skin
involving the petrous bone
and skull base leads to
osteomyelitis (malignant
otitis externa). Oral and IV
antifungals (amphotericin,
ketaconazole, itraconazole)
are often required.
Acute localised otitis
externa (furunculosis)
A furuncle is a localised
staphylococcal abscess arising from the base of a hair
follicle (figure 7). In the ear
canal, they only occur in the
lateral cartilaginous portion.
As the skin is tightly adherent to the underlying perichondrium, movement of the
pinna causes significant pain.
Treatment involves systemic and/or topical antistaphylococcal antibiotics. If
the abscess is pointing,
drainage with a sterile hypodermic needle will accelerate
resolution. The ear canal
may also be packed with an
otowick or antibioticimpregnated vaseline gauze
(Xeroform).
Acute diffuse otitis
externa
In essence, acute otitis
externa is a cellulitis of the
ear canal skin and the underlying subdermis. Acute diffuse otitis externa may
involve the ear canal, pinna
or tympanic membrane. In
North America, 98% is bacterial, due to P aeruginosa
(20-60% prevalence) and S
aureus (10-70% prevalence).
Early infection (‘swimmer’s ear’ or ‘tropical ear’)
is one of the most common
infections presenting to primary care physicians. The
annual incidence in the US
and Canada is between
1:100 and 1:250 of the general population. Regional
variations depend on age
and location. Lifetime incidence is about 10%.
Acute diffuse otitis externa
is rapid in onset (usually
within 48 hours) and associated with erythema and
oedema of the ear canal skin.
There may be clear and/or
odourless secretions and some
desquamated debris within the
canal. Pain is mild and there
AD_HTT_025_032___APR13_07 4/4/07 4:10 PM Page 29
Table 6: Clinical signs and symptoms of acute otitis externa
Table 7: Differential diagnosis of acute otitis externa
Signs and symptoms
Comment
Otalgia/pain (70%)
Often intense except in the early stage. More pronounced with
bacterial infections
Usually circumferential. Blebs and bullae may be present
May extend into the pre- and post-auricular soft tissues
Mild-moderate. May be green or white. Usually not copious or
serosanguineous. Does not usually stain the bed sheets
White, creamy. If fungal, spores may be seen, eg, black
conidiophores of Aspergillus niger. Pseudomonas aeruginosa has
a typically green hue
Early stages and healing phase. More common with dermatitis
and fungal otitis externa
Depends on canal stenosis and debris. More common with acute
otitis media
Oedema
Erythema
Otorrhoea
Debris in the canal
Itchiness
Hearing loss
may be discomfort with movement of the tragus (classic
sign). The tympanic membrane may appear dull.
As the inflammation
increases, the patient complains of increasing pain and
itching. Oedema tightens the
ear canal and there is further
accumulation of debris.
Tragal pressure and pulling
of the pinna causes greater
pain and it may be difficult
to examine the ear canal
with the otoscope. Visualising the tympanic membrane
can also be difficult.
In severe acute otitis
externa there may be cellulitis and oedema of the preand post-auricular tissues.
Extension into the upper
neck is possible, though rare.
The pain can be very severe,
Clinical
presentation
History
Pain
Fever
Discharge
Associated features
Season
Acute otitis media
(with perforation)
Chronic suppurative
otitis media*
Often severe
Before perforation
Rare
Thick,
mucopurulent
Swimming, warm
or humid weather
Before rupture
Often copious, may be
serosanguineous
URTI, grommet in situ
Summer
Winter or spring
Uncommon, unless
complication present
Rare
Purulent, chronic or
recurrent
Chronic tympanic
membrane perforation ±
cholesteatoma
Variable
Physical examination
Ear canal
Tender tragus or
pinna, oedema,
erythema
Figure 9 A: Chronic suppurative otitis media with attic
cholesteatoma. B: Radiation osteitis (previous radiation
exposure with resultant osteitis is a predisposing risk factor for
the development of otitis externa).
A
Otitis externa
Tympanic membrane
B
Organisms
Normal or mild
inflammation. May
be difficult to
visualise
Pseudomonas
aeruginosa,
Staphylococcus
aureus
(skin pathogens)
Copious discharge. Pain is
related to associated
secondary otitis externa
Chronic discharging
ear, offensive odour.
Pain might indicate
complication
Perforated, red, inflamed,
Larger perforation,
opaque. Gentle forced
squamous or keratin
Valsalva manoeuvre may
debris. Consider
produce bubbles
cholesteatoma
Streptococcus pneumoniae, Pseudomonas
Haemophilus influenzae,
aeruginosa,
Moraxhella catarrhalis
Staphylococcus
(respiratory tract pathogens) aureus, coliforms,
others
*Includes tympanostomy tube otorrhoea
required.
In children examination of
the tender ear is even more
challenging. Acute otitis
media is more common, particularly in the younger age
groups. Otitis externa is
more likely if the child is
older (12-18 years) or if
there is:
■ A history of swimming.
with associated fever, nausea
and vomiting. Patients avoid
sleeping on that side and a
significant number cannot
sleep at all because of pain
and distress.
Simple analgesia such as
paracetamol, low-dose oral
opioids and NSAIDs may
appear ineffective. Parenteral
opioids are sometimes
A history of trauma to the
ear canal and/or excessive
cleaning.
■ An underlying skin disorder.
■ A history of chronic suppurative otitis media.
■ Hearing aid use.
■ Immunocompromise.
■ Diabetes.
A microbiology swab and
culture can often help distin■
guish between external and
middle-ear infections. Antibiotic sensitivity will provide
a guide for appropriate
antimicrobial therapy.
Tympanometry is a noninvasive investigation that
helps distinguish between an
intact or perforated tympanic membrane. It is generally well tolerated by chil-
dren. However, the patient
with acute otitis externa will
often experience significant
pain on insertion of the ear
probe. In the acute setting it
has limited usefulness.
Table 7 highlights the clinical differences between
otitis externa, acute otitis
media and chronic suppurative otitis media (figure 9).
Managing acute otitis externa
Evidence-based medicine
COMPARED with other subspecialities there are relatively few
guidelines relating to otorhinolaryngological diseases. An algorithm for the management of diffuse acute otitis externa is shown in
figure 10 (page 30).
In 2006, the American Academy
of Otolaryngology – Head and
Neck Surgery produced an evidence-based guideline* for the
treatment of acute otitis externa,
based on numerous clinical and scientific studies as well as large metaanalysis. The information below is
adapted from this guideline.
Table 8: Topical antimicrobials for diffuse acute OE
Topical agent
Components
Dosing
Side effects
Advantages
Disadvantages
Sofradex
Framycetin, gramicidin,
dexamethasone
Neomycin, gramicidin,
nystatin, triamcinolone
2-3 drops
tds or qid
2-3 drops
bd or tds
Ototoxicity
Broad-spectrum, steroid
reduces pain, inexpensive
Broad-spectrum, steroid,
reduces pain, antifungal
component
Ciproxin HC
Ciprofloxacin
hydrochloride,
hydrocortisone,
benzyl alcohol
3 drops bd
Headache, leaves
precipitate (skin cast)
within ear canal
Ototoxicity with TM perforation,
poor compliance
Ototoxicity, hypersensitivity,
viscous, poor compliance,
neomycin not effective against
Pseudomonas aeruginosa
Relative cost, contraindicated
with TM perforation (contains
alcohol preservative)
Ciloxan 0.3%
ear drops
Ciprofloxacin
hydrochloride
(3mg/mL)
3 drops tds
Burning (mild)
Locacorten-Vioform
Flumethasone,
clioquinol,
polyethylene glycol
Chloramphenicol, boric acid,
borax, phenylmercuric nitrate
3 drops bd
Itching/burning
4 drops qid
Local irritation, blood
dyscrasia, superinfection
Kenacomb
Ototoxicity, neomycin
skin hypersensitivity,
burning
Prevention
There is level C evidence for efficacy of the following measures in
preventing otitis externa:
■ Avoiding water and humidity
(swim plugs, drying agents, hair
dryer on low setting).
■ Avoiding trauma to the ear canal
(foreign objects, excessive
removal of wax).
■ Avoiding ear syringing in patients
with tight stenotic or tortuous ear
canals.
■ Treating underlying dermatitis
(seborrhoeic, atopic).
■ Avoiding ear drops containing
neomycin (skin hypersensitivity
in 5-15% of patients with chronic
otitis externa).
*American Academy of Otolaryngology
– Head and Neck Surgery. Clinical
practice guideline: acute otitis externa.
Otolaryngology – Head and Neck
Surgery 2006; 134 [Suppl 4S (April)].
Chloromycetin
ear drops
High efficacy against
Pseudomonas aeruginosa,
Staphylococcus aureus,
Proteus species. Steroid
reduces pain. No
fluoroquinolone ototoxicity
No ototoxicity, can be
used with TM perforation.
Recently released as otic
preparation
Very good against fungal
otitis externa, steroid
reduces itch and pain
Bacteriostatic across a
wide range of pathogens
No steroid component
Caution with TM perforation.
Viscous, difficult to instil
Contraindicated with
TM perforation
TM = tympanic membrane
Treating discharging middle ear
(chronic suppurative otitis media,
tube otorrhoea)
■ Controlling systemic disease (diabetes, HIV infection, immunocompromise).
■ Avoiding radiotherapy to the
head and neck.
■
Pain management
This is a major goal in the management of acute otitis externa.
There is level B evidence for the
following measures:
■ Mild-moderate pain usually
responds to paracetamol or
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NSAIDs alone or in combination
with an opioid (codeine, oxycodone). Fixed-interval analgesia
may be more effective than when
used as needed. Although popular, adjunctive therapies such as
heat, cold and distraction are of
unproven value.
■ Benzocaine-containing otic preparations (Auralgin Otic) can provide topical anaesthesia for the
ear canal, although there have
been no clinical trials to establish
efficacy. The use of these drops
may allow disease progression to
be masked. Topical benzocaine
may induce a contact hypersensitivity dermatitis.
Topical steroids added to ototopical antibiotic drops (Cipro-HC,
Sofradex) have been shown to
hasten pain relief.
Initial therapy — topical vs
systemic
There is level B evidence supporting
the use of topical vs systemic therapy in the initial stages.
Topical preparations are recommended for uncomplicated acute
otitis externa (no osteitis, abscess,
cont’d next page
13 April 2007 | Australian Doctor |
29
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How to treat – external ear conditions
from previous page
Figure 10. Algorithm for the management of diffuse acute otitis externa.
middle-ear disease, tympanic membrane perforation or recurrent
episodes of infection).
Coexistent diabetes, immunosuppression or spread of disease
beyond the ear canal into the
pinna, skin of the face or neck or
deeper tissues (malignant otitis
externa) requires referral to an
ENT specialist and use of oral or
IV therapy.
Studies have shown that 20-40%
of patients with acute otitis externa
receive oral antibiotics, often as
well as topical antimicrobials.
Many of the oral antibiotics are
inactive against Pseudomonas and
S aureus, the most common
pathogens. Treatment with penicillins, cephalosporins or macrolides
increases disease persistence, and
treatment with cephalosporins also
increases recurrence.
Ototopical therapies have several
advantages over systemic therapy
for uncomplicated, diffuse acute
otitis externa. These include:
■ High concentration of medication
at the site of infection (100-1000
times higher than that achieved
with systemic therapy).
■ Low risk of developing antibiotic
resistance.
■ Minimal systemic adverse effects
(rashes, vomiting, diarrhoea,
allergic reactions and altered
nasopharyngeal flora).
■ Relative ease of administration.
Which topical therapy?
Level B evidence supports the following recommendations regarding choice of topical therapy.
It is not always necessary to treat
diffuse acute otitis externa with an
antibiotic. Several acidifying solutions are available, including:
■ Acetic acid.
Patient >two years with
diffuse acute otitis externa:
■ Ear pain
■ Discharge
■ Tragal tenderness
Vesicular eruption
Treat for herpes zoster oticus
Yes
No
Analgesia according to
pain severity
Extension beyond ear canal
Referral to ENT specialist
■ May require admission and
parenteral antibiotics.
■ Management of underlying
conditions
Yes
No
Tympanic membrane
perforation
(known or suspected),
including in situ grommet
Yes
Non-ototoxic topical therapy
(ciprofloxacin)
No
Topical therapy
Patient preference, cost,
compliance
Requires aural toilet
+/- otowick insertion
May require referral to ENT
specialist
Yes
Obstructed ear canal
No
Educate patient
■ Water avoidance
■ Drop delivery
Clinical improvement in
24-48 hours
Clinical re-assessment
■ Swab culture
■ Aural toilet
■ Assess for compliance
■ Exclude other illnesses
No
Yes
Complete course
Treat modifying and
redisposing factors
■ Dermatitis
■ Ear canal trauma
■ Water exposure
■ Hearing aids
■ Diabetes/
immunosuppression
Boric acid.
Aluminium acetate.
■ Silver nitrate.
■ Glycerine-ichthammol.
■
■
Gentian violet.
These agents are inexpensive and
have been used for many years,
particularly in developing countries. They are unlikely to cause
bacterial resistance.
Ototopical antibiotics contain
either an aminoglycoside (gentamycin, neomycin, tobramycin,
polymyxin B and framycetin) or
fluoroquinolone (ciprofloxacin,
ofloxacin).
Aminoglycosides have been
around for longer, are generally
cheap and have a good antibacterial spectrum for acute otitis externa
but in recent years, aminoglycoside
ototoxicity (cochlear and vestibular) has become more apparent.
Topical gentamicin drops delivered
via a middle-ear catheter or grommet (ventilating tube) are sometimes used to perform chemical
labyrinthectomy in patients with
Ménière’s disease.
Aminoglycosides and topical alcohol-containing agents should not be
used when the tympanic membrane
is perforated and the middle-ear
space is open. The risk of ototoxic
injury outweighs the benefits compared with non-ototoxic antimicrobials with equal efficacy.
Ototopical antimicrobial treatments for acute otitis externa are
shown in table 8 (page 29).
Meta-analysis has shown no significant difference in clinical outcomes (clinical and bacteriological
cure rates) for patients with acute
otitis externa with regard to use of:
■ Antiseptic vs antimicrobial.
■ Quinolone vs non-quinolone
antibiotic.
■ Steroid-antimicrobial vs antimicrobial alone.
Regardless of the topical agent
used, 65-90% of patients have
clinical resolution within 7-10 days.
■
Recent studies have shown significant differences in the rapidity of
treatment response and symptom resolution. The addition of hydrocortisone to ciprofloxacin significantly
reduced median ear pain by one day.
Drug delivery
Drug delivery may be difficult if
there is extensive debris in the ear
canal or skin oedema. Self-administration can also be difficult. Level
C evidence exists for the following
guidelines regarding delivery of
topical therapy.
Ideally the ear canal should be
cleared of inflammatory debris,
obstructing wax or other foreign
body. Aural toilet can be done with
hydrogen peroxide, but best results
are achieved with the use of suction or cotton wool brooch.
If canal oedema prevents adequate delivery of drops, an otowick, comprised of compressed cellulose, can be placed in the ear
canal. The wick is simply inserted
dry into the ear canal using forceps. Ideally the visible end
should sit flush with the level of
the conchal bowl. The wick
expands when exposed to moisture and optimises drug delivery
while reducing canal oedema.
Otowicks should be changed after
48 hours.
Drops should be applied with the
patient lying down with the
affected ear upwards. After the
drops have been placed, instruct
the patient to rub the tragus, as this
eliminates any trapped air in the
ear canal, and allows the drops to
reach the medial ear canal and
tympanic membrane. If the patient
states that the drops can be tasted,
tympanic membrane perforation
should be suspected, even if not
clinically apparent.
Other conditions of the external ear
Malignant (necrotising)
otitis externa
MALIGNANT otitis externa
is an aggressive and invasive
form of otitis externa. It
typically affects elderly
or immunocompromised
patients and those with diabetes. Important to the
pathophysiology appears to
be alteration of the canal pH.
The aetiology may be bacterial or fungal. P aeruginosa
is the most common
pathogen. The infection
starts in the ear canal skin
then extends into the temporal bone. Skull base
osteomyelitis may extend
medially to involve multiple
cranial nerves and the
intracranial contents.
The diagnosis is based on
the clinical findings. A hallmark of malignant otitis
externa is an area of granulation tissue on the floor of
the cartilaginous ear canal,
near the junction of the bony
portion of the ear canal. The
associated pain can be severe
and response to standard
treatment can be slow.
A poor clinical response to
treatment, together with
other risk factors such as diabetes, being elderly or
immunocompromised, neces-
30
Figure 11: Gallium scan for
skull base osteomyelitis.
Figure 12 A: Squamous cell carcinoma of the ear canal.
B: Lateral temporal bone resection. C: The ear canal is
transected. D: Superficial parotidectomy.
A
B
tures of the temporal bone,
skull base, parotid and neck
necessitate wide surgical
excision (figure 12) with
adjuvant chemo/radiotherapy.
Bullous myringitis
sitates urgent review by an
ENT specialist.
A gallium scan (gallium 67
citrate) (figure 11) indicates
the extent of inflammation
and quickly returns to
normal with the resolution
of infection. Technetium
bone scans reflect activity in
osteoblasts and osteocytes.
These scans may remain positive for many months after
clinical resolution.
When the condition was
first described in the late
1950s / early 1960s, the mortality rate approximated
80%. Prognosis is now much
improved.
Treatment requires IV and
prolonged oral antibiotics,
often with adjunctive topical therapy. Effective antibiotics include ciprofloxacin,
piperacillin-tazobactam
(Tazocin), ticarcillin-clavulanate (Timentin) and cef-
| Australian Doctor | 13 April 2007
C
D
tazidime. Adjuvant hyperbaric oxygen therapy has
also achieved good results in
selected centres.
Malignant tumours of the
external ear
Melanoma, squamous cell
and basal cell carcinoma
commonly affect the sunexposed auricle. These are
often easy to diagnose. When
malignancies involve the ear
canal, diagnosis can be diffi-
cult and may be delayed.
Rare tumours involving skin
adnexal structures and minor
salivary glands can also
occur.
The clinical presentation
may be similar to that of
otitis externa with a history
of chronic ear discharge, a
mass in the ear canal, hearing loss or facial palsy.
Metastases are present at the
time of diagnosis in 5-15%.
Extension into deeper struc-
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This is a distinct form of
otitis externa, characterised
by fluid-filled haemorrhagic
blebs on the tympanic membrane and deep ear-canal
skin. Severe local pain followed by a spontaneous
haemoserous discharge is
common. Influenza viruses
and Mycoplasma pneumoniae are suspected causative
agents.
A conductive hearing loss
as a result of secondary
serous otitis media may
occur. In rare case the inner
ear can be involved, with
clinical sensorineural hearing
loss and vertigo. Treatment
is generally supportive, with
analgesia and prevention of
secondary bacterial infection.
involved include the nose,
eustachian tube, larynx, ribs
and joints.
The condition is more
common in women aged 3545. The pinna may appear
beefy red, with sparing of the
ear canals and ear lobes.
Treatment is with systemic
steroids and salicylates.
Referral to an immunologist
or rheumatologist may be
indicated.
Temporal bone fractures
These may be the result of
head injury. The direction
and force of the impact often
determine the alignment of
fracture (longitudinal, transverse, mixed or obtuse). The
clinical picture may include
bloody ear discharge, haemotympanum, hearing loss and
facial palsy.
Online resources
Hawke Library:
www.hawkelibrary.com
■ Otolaryngology Houston:
www.ghorayeb.com
■ The Ohio State University
College of Medicine:
www.medicine.osu.edu
■
Relapsing polychondritis
This is an episodic, recurring
inflammatory disorder
affecting auricular cartilage.
Scleral involvement may present as a visual impairment.
Other areas that may be
AD_HTT_025_032___APR13_07 4/4/07 4:10 PM Page 32
How to treat – external ear conditions
GP’s contribution
traindicated, because the
patient has marked pain, and
coexisting tympanic membrane perforation has not
been excluded. A swab can be
taken for culture to confirm
the diagnosis.
I would prescribe adequate
analgesia and start ototopical
ciprofloxacin (Ciloxan 0.3%),
3-4 drops bd. Cipro-HC
drops (three drops bd) are also
effective if the tympanic membrane is intact. The ear should
be kept strictly dry.
Poor clinical response at
48 hours would be an indication for review at a tertiary hospital.
of a paper tissue. The right ear
canal and drum look normal.
All the local ENT practices
are closed until mid-January
at the earliest, and the local
hospital has no ENT surgeon
on call.
DR ROSS WHITE
Questions for the author
Beecroft, NSW
Case study
JUST after Christmas,
Michael, 12, presented with a
painful left ear of two days’
duration. He had been away
at a relative’s farm and had
swum in a dam with his
cousins. He has a history of
perforated eardrum with an
acute middle-ear infection at
age eight, but his mother
cannot remember which ear.
He is afebrile, the tragus is
very tender, and moving the
pinna causes a lot of pain. The
canal is filled with loose lightcoloured debris and there is a
small amount of yellowish discharge. The ear is too tender
to remove any of the material,
even with a twist of a corner
Should any attempt be made
to syringe this ear or should
Michael be referred to a tertiary hospital for ear toilet and
management?
My provisional diagnosis
is acute diffuse bacterial
otitis externa. The most
likely organism is P aeruginosa. The features in the
clinical history that support
this diagnosis include rapid
onset of pain and a history
of swimming in a dam. Tenderness with tragal manipulation and the finding of
debris without copious discharge also support the diagnosis. Acute otitis media is
far less common in this age
group.
Ear syringing is con-
Would oral flucloxacillin
and topical ciprofloxacin be
worth starting without any
ear toilet?
Topical ciprofloxacin provides excellent coverage for
S aureus as well as other
Gram-positive and Gram-negative bacteria. Adjuvant oral
antibiotics might be considered for disease spread into
How to Treat Quiz
INSTRUCTIONS
External ear conditions
— 13 April 2007
FAX BACK
Photocopy form
and fax to
(02) 9422 2844
1. With respect to the external ear canal,
which TWO of the following are correct?
❏ a) The lateral (cartilaginous) portion of the
external ear canal has tightly adherent skin
that produces no wax
❏ b) The external ear is innervated by the
greater auricular nerve as well as cranial
nerves V, VII, IX and X
❏ c) The auricular cartilage is continuous with
the lateral one-third of the external ear
canal
❏ d) The epithelium of the lateral tympanic
membrane moves medially to the middle
ear space
2. Soft brown wax in the external ear canal
of Caucasians and dark-skinned people
helps maintain external ear health in which
TWO ways?
❏ a) Immunoglobulins in the wax, with other
constituents such as lysozymes, act in
association with an intact skin epithelium
to protect the external ear from infection
❏ b) The pH of healthy wax (4-5) discourages
bacterial and fungal pathogens
❏ c) More acidic wax in people with diabetes
(pH 3-4) provides extra infection protection
❏ d) When infection is present in the external
ear canal increased wax production helps
fight infection
3. With respect to foreign bodies and
obstruction of the external ear canal,
which THREE of the following are true?
❏ a) Exostoses can cause conductive hear-
ing loss through obstruction with keratin
and wax and direct contact with the lateral
surface of the tympanic membrane
❏ b) Live insects such as cockroaches may
cause drum rupture
❏ c) Osteomata occur most commonly in the
anterior-superior portion of the ear canal
and rarely cause symptoms
❏ d) Ticks can be left for a period of two
weeks and will eventually be expelled
4. Jeffrey, 58, presented to his GP
complaining of pain in the right ear. On
examination his right external ear canal
was very inflamed and tender. Jeffrey has
a history of seborrhoeic dermatitis and has
just returned from a surfing safari in Bali.
Which TWO of the following are the most
likely diagnosis?
❏ a) Infective otitis externa
❏ b) Otitis media with effusion
❏ c) Chronic suppurative otitis media
❏ d) Fungal otitis externa (otomycosis)
5. Jeffrey is treated with antibiotic ear
drops but over the next 24 hours develops
facial pain and sensitivity of the skull and
scalp on the right side of his head. His
wife finds small “scabs” on his pinna and
in the external ear canal. Which THREE of
the following would support a diagnosis of
herpes zoster oticus (Ramsay Hunt
syndrome)?
❏ a) Mastoid pain
❏ b) Decreased taste sensation on the right
peri-auricular tissues.
Are there any concerns about
aural ciprofloxacin on the
development of the middle-ear
ossicles and the ossicular
joints in young children with
perforated tympanic membranes?
Oral administration of
ciprofloxacin and other
quinolones has been shown to
cause arthropathy in immature animals. There is no evidence that otic dosing has any
effect on weight-bearing joints
or ossicular structures. Topical
ciprofloxacin is indicated for
chronic suppurative otitis
media or open tympanic
cavity in adults and children
aged one month or older.
General questions for the
author
For the removal of cerumen,
are electronic ear irrigators
(eg, ‘Propulse’ or ‘Otoscillo’)
any safer than a standard
metal ear syringe?
Electronic ear irrigators
allow pressure-controlled
warm-water irrigation of the
ear canal to remove cerumen,
which the manufacturer states
is the main advantage over
traditional metal syringes.
They should only be used by
experienced doctors, audiologists or nurses, and the same
contraindications apply.
How should a GP distinguish
keratosis obturans from a
cholesteatoma of the external
auditory canal?
Keratosis obturans is essentially a keratin plug obstructing the ear canal. Pressure on
the bony ear canal can lead to
erosion or smooth widening
of the ear canal. Bilateral presentation can occur and is
more commonly found in
younger patients.
External canal cholesteatoma involves bone erosion and periostitis. Unilateral
presentation in an older age
group is more common.
Both conditions are best
treated by ENT specialists.
Complete this quiz to earn 2 CPD points and/or 1 PDP point by marking the correct answer(s) with an X on this form.
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side of his mouth and tongue
❏ c) Hearing loss and tinnitus
❏ d) Drooping of the right side of his mouth
but normal movement of the upper face,
including the forehead and muscles around
the eye
6. Treatment of Ramsay Hunt syndrome
can include which THREE of the following?
❏ a) Patching and eye protection if there is
incomplete eyelid closure
❏ b) Antiviral medication such as valaciclovir
or famciclovir
❏ c) Urgent grommet insertion to minimise
hearing loss
❏ d) Oral steroids
7. Features of history, examination and
investigation that help differentiate otitis
externa from acute otitis media include
which THREE of the following?
❏ a) A recent history of a lot of swimming
❏ b) The appearance of the tympanic membrane
❏ c) The season — acute otitis media is more
common in summer, and otitis externa in
winter
❏ d) Microbiological findings on ear swab
8. Which THREE of the following are
recommended in the management of acute
otitis externa?
❏ a) Topical antibiotics
❏ b) Oral steroids
❏ c) Avoidance of aminoglycoside or alcohol
ONLINE
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drops if the tympanic membrane is perforated
❏ d) The use of an otowick if canal oedema
prevents adequate delivery of drops
9. Julian, 74, has diabetes and difficulty
using his hearing aid because of ear wax.
Three days after using a cotton bud in his
ear he presents to you with severe pain in
his ear. Which TWO features would
suggest that his ear pain is due to
malignant necrotising otitis externa?
❏ a) Antibiotic drops prescribed two days
ago by another doctor have made no difference to his symptoms
❏ b) His age and diabetes
❏ c) On examination, an area of granulation
tissue adjacent to the ear drum
❏ d) Vesicles in his conchal bowl
10. Aware that, in a patient such as Julian,
this may be malignant necrotising otitis
externa you refer him urgently to an ENT
surgeon. With respect to his management
and prognosis, which TWO of the following
are true?
❏ a) Even if treated early, this problem has a
mortality rate of 80%
❏ b) Treatment requires IV and prolonged
antibiotics
❏ c) Hyperbaric oxygen therapy has achieved
good results in some centres
❏ d) Resolution of abnormalities on
technetium bone scan occur early when
appropriate treatment is introduced, and
is a good gauge of clinical success
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HOW TO TREAT Editor: Dr Martine Walker
Co-ordinator: Julian McAllan
Quiz: Dr Martine Walker
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Your CPD activity will be updated on your RACGP records every January, April, July and October.
NEXT WEEK Available evidence continues to suggest considerable room for improvement in the recognition, treatment and control of hypertension in the primary care setting. But not all cases are
straightforward. The next How to Treat looks at the more difficult cases of resistant hypertension. The author is Professor David W Johnson, director of nephrology and chair of medicine, Princess
Alexandra Hospital, Brisbane; professor of medicine, University of Queensland, St Lucia, Brisbane, Queensland.
32
| Australian Doctor | 13 April 2007
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