Otitis Externa

Otitis externa, commonly known as swimmer’s ear, is an inflammation of the external auditory canal. In Australia, like many other places, it can be frequently seen during the summer months when swimming activities increase, but it’s not limited to swimmers or the summer season.

Diagnosis of Otitis Externa

History:

  • Ear pain (otalgia), often worsening with movement of the ear or jaw.
  • Itching in the ear canal.
  • Discharge from the ear, which can be clear, white, yellowish, or sometimes pus-like.
  • History of recent water exposure (swimming, bathing) or trauma from ear cleaning (cotton swabs, fingernails).
  • Patients may also report hearing loss or a feeling of fullness in the ear.

Physical Examination:

  • Inspection and palpation of the external ear and tragus may elicit pain.
  • Otoscopic examination reveals an erythematous, swollen ear canal, sometimes with discharge or debris. The eardrum may be difficult to visualize due to swelling.
  • Lymphadenopathy in the neck might be present.

Differential Diagnosis

  • Acute Otitis Media: Infection of the middle ear, pain without movement of the outer ear, often associated with systemic symptoms like fever.
  • Foreign Body: Especially in children, can cause pain and discharge.
  • Eczema or Psoriasis: Can affect the ear canal and cause itching and flaking but usually less pain than otitis externa.
  • Malignant (Necrotizing) Otitis Externa: A severe, potentially life-threatening infection that typically affects immunocompromised individuals, especially those with diabetes.

Management of Otitis Externa

General Measures:

  • Advise keeping the ear dry (avoid swimming and use of earplugs while showering).
  • Pain management with analgesics such as paracetamol or ibuprofen.
  • Consider swab for MCS

Management:

  • Topical:
    • Bacterial – Dexamethasone/Framycetin/Gramicidin (Sofradex) 3 drops BE TDS for 7 days
    • Fungal – Flumetasone/Clioquinol (Locacorten) 3 drops BE BD for 7 days
    • Both – Triamcinolone/neomycin/gramicidin/nystatin (Otacomb Otic) 3 drops BE TDS for 7 days
  • Oral
    • Flucloxacillin 500mg oral QID + Ciprofloxacin 750mg oral BD for 7-10 days
      • Keflex 500mg oral QID or Clindamycin 450mg oral TDS for 7-10 days (penicillin allergy)
  • Cleaning: Gentle cleaning of the ear canal to remove debris or discharge allows topical medications to reach the affected area.
  • Ear Wick: For very swollen ear canals a wick will improve antibiotic penetration

Follow-Up:

  • Follow-up is recommended if symptoms do not improve within 48-72 hours of initiating treatment.
  • Persistent or recurrent cases may require further investigation to exclude other conditions or underlying causes such as diabetes or skin conditions.

Preventative Measures:

  • Ear plugs or a swimming cap can be used to keep the ears dry during water activities.
  • Avoiding the insertion of foreign objects into the ear, including cotton swabs.
  • Drying ears thoroughly after water exposure, using a towel or a hair dryer on a low and cool setting.
  • Medication: Acetic acid/Isopropyl alcohol (Aqua ear)

Referral:

  • Referral to an ENT specialist may be necessary for severe cases, failure to respond to treatment, or if there is suspicion of malignant otitis externa.

ATSI:

In the case of Aboriginal and Torres Strait Islander populations, it’s important to consider the higher prevalence of chronic ear diseases. In these groups, otitis externa may be part of a broader pattern of ear disease, requiring comprehensive management and follow-up to prevent long-term complications such as hearing loss. Community health interventions that address environmental health, hygiene, and access to medical care are vital in reducing the burden of ear diseases, including otitis externa, in these communities.