Managing Otitis Externa: No Diving Zone

-Case-
A 17-year-old high school swimmer presents with right ear pain, especially when tugging on the pinna. He has some ear fullness and mild hearing loss. On exam, the external canal is erythematous with debris, and tragal tenderness is present.

-Evaluation-
Otitis externa (OE) is inflammation or infection of the external auditory canal, most often due to bacterial infection following moisture exposure (hence the classic term “swimmer’s ear”). Common pathogens include Pseudomonas aeruginosa and Staphylococcus aureus.

  • Symptoms:
    • Otalgia (worsens with tragus or pinna movement)
    • Pruritus
    • Ear fullness or hearing loss
    • Discharge from the ear canal
  • Physical Exam:
    • Tenderness with tragal or pinna manipulation
    • Erythema and edema of ear canal
    • Purulent debris
    • Tympanic membrane usually visible and normal

Risk Factors:

  • Water exposure (swimming, humid environments)
  • Ear trauma from Q-tips or hearing aids
  • Chronic skin conditions (eczema, psoriasis)

-Management-

  • Topical antibiotic drops are the mainstay- think fluoroquinolones (e.g., ciprofloxacin)
  • Ear wick for severe edema preventing ear drop penetration
  • Pain control with NSAIDs or acetaminophen
  • Avoid ear canal manipulation and water exposure until symptoms resolve
  • Oral antibiotics only for refractory or complicated cases (e.g., cellulitis extending beyond ear)

-Malignant Otitis Externa:-
Be alert for this rare but serious complication, especially in elderly diabetics or immunocompromised patients.

  • Presents with deep ear pain, cranial nerve deficits, and persistent symptoms
  • Requires IV antibiotics and ENT consult

-Fast Facts-

  • OE is primarily treated with topical agents
  • Pain with tragal pressure is a distinguishing feature
  • Fungal OE (otomycosis) presents with more pruritus and black/white debris
  • Prevention includes drying ears after water exposure and avoiding Q-tip use

That painful, itchy ear might just be swimmer’s ear; treat it right and you’ll have patients diving back into comfort in no time. Just remember, not all ear pain is created equal, and tragal tenderness can lead you to the right diagnosis.

Want to learn more? Listen to our podcast episode on this topic!

Cheers,

Tamir Zitelny, MD

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-References-

  1. Roland PS, Stroman DW. Microbiology of acute otitis externa. Laryngoscope. 2002;112(7 Pt 1):1166-1177.
  2. Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014;150(1 Suppl):S1-S24.
  3. Prasad SC, Kotian RN, Thada ND, et al. Malignant otitis externa: Surgical and radiological perspectives. Ann Otol Rhinol Laryngol. 2014;123(11):804-811.
  4. Blyth CC, Gomes L, Sorrell TC. Otitis externa: an update. Aust Fam Physician. 2017;46(5):301-305.
  5. Rowlands S, Devalia H, Smith C, Hubbard R, Dean A. Otitis externa in UK general practice: a survey using the UK General Practice Research Database. Br J Gen Pract. 2001;51(468):533-538.
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