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ENT (Ear, Nose, Throat Conditions)

Otitis Externa

Inflammation or infection of the external auditory canal (EAC) skin. Can be localized (furuncle) or diffuse.

Also known as: Swimmer's Ear, Outer Ear Infection

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Referral and warning signs

When to refer

Refer to ENT Specialist/Hospital if: Severe pain unresponsive to analgesia. Complete canal occlusion due to swelling (may need wick insertion). Suspected Malignant Otitis Externa. Failure to respond to topical treatment after 1 week. Suspected fungal infection unresponsive to initial therapy. Recurrent otitis externa.

Red flags

  • Severe pain out of proportion to findings.
  • Facial weakness.
  • Vertigo.
  • Signs suggesting Malignant Otitis Externa (persistent deep pain, granulation tissue in canal floor, cranial nerve palsies).
  • Cellulitis extending beyond the ear canal.

Signs and symptoms

  • Ear pain (otalgia) - often severe, worsened by pulling the pinna (tragal sign) or chewing.
  • Itching (pruritus) - especially prominent in fungal otitis externa (otomycosis).
  • Feeling of fullness or blockage in the ear.
  • Ear discharge (otorrhoea) - may be watery, purulent, or thick; white/black debris suggests fungal.
  • Hearing loss (conductive, due to canal swelling/debris).
  • Tenderness on palpation of tragus or manipulation of pinna.
  • Redness and swelling of the ear canal skin.
  • Localized boil (furuncle) may be visible.
  • Cellulitis of pinna or surrounding skin (severe cases).

Risk factors

  • Swimming (water exposure macerates skin).
  • Trauma to ear canal (cotton buds, scratching, hearing aids).
  • Hot, humid climate.
  • Skin conditions (eczema, psoriasis).
  • Diabetes mellitus.
  • Immunosuppression.
  • Narrow ear canals.

Diagnosis

Clinical assessment

Diagnosis based on symptoms (pain worsened by pinna movement, itch) and otoscopic findings (red, swollen canal, debris, discharge). Differentiate from otitis media with perforation (discharge present, but canal skin usually not inflamed, pain less related to pinna movement).

Investigations

  • Otoscopy is key.
  • Swab of discharge for Gram stain, Fungal smear (KOH), Culture & Sensitivity (if severe, recurrent, or unresponsive to treatment).

Diagnostic criteria

Clinical diagnosis based on characteristic symptoms and signs of external auditory canal inflammation.

Differential diagnosis

  • Acute Otitis Media with perforation.
  • Chronic Suppurative Otitis Media (CSOM).
  • Foreign body in ear.
  • Impacted cerumen.
  • Herpes zoster oticus (Ramsay Hunt syndrome - vesicles, facial palsy).
  • Eczema of ear canal.
  • Malignant Otitis Externa (invasive infection in diabetics/immunocompromised).

Management

Non-pharmacological management

  • Aural Toilet: Thorough cleaning/clearing of the ear canal (debris, discharge, wax) by trained personnel using suction or dry mopping. Essential for topical medication penetration.
  • Keep ear dry - avoid swimming, protect during bathing.
  • Pain relief.
  • Remove any predisposing factors (e.g., hearing aids temporarily).

Pharmacological treatment

  • Topical Preparations (Mainstay):
  • - Antibiotic +/- Steroid Drops: (Treats bacterial infection and inflammation).
  • - E.g., Ciprofloxacin +/- Dexamethasone drops.
  • - E.g., Neomycin/Polymyxin B/Hydrocortisone drops (Caution: Neomycin ototoxicity risk if perforation).
  • - UCG Recommendation: Chloramphenicol ear drops 0.5% 2 drops TID/QID for 14 days. (LOC: HC2)
  • - Instill drops generously, patient lying with affected ear up for few minutes.
  • - Use for 7-14 days.
  • - Acidifying Agents +/- Steroid: (Acetic acid preparations) - Restores acidic pH, inhibits bacteria/fungi.
  • - Antifungal Drops (If Otomycosis suspected/confirmed):
  • - Clotrimazole 1% solution: Apply once WEEKLY for 4-8 weeks (after cleaning). (LOC: HC3)
  • - Alternatives: Acetic acid, specific antifungal drops.
  • Oral Antibiotics (If severe swelling/cellulitis spreading beyond canal OR immunocompromised):
  • - Cover Pseudomonas and Staph aureus.
  • - E.g., Ciprofloxacin PO.
  • - UCG Recommendation (Severe): Cloxacillin 250-500mg QID for 5-7 days (Child: 12.5-25mg/kg/dose). (LOC: HC4)
  • Analgesia: Paracetamol, NSAIDs.
  • Systemic Antifungals (Rare, for invasive fungal OE):
  • - UCG Suggestion: Fluconazole 200mg OD for 10 days (if fungal suspected). (LOC: HC3)

Monitoring

Assess response within 48-72 hours. Follow up until resolution. Consider referral if no improvement.

Complications

  • Chronic otitis externa.
  • Canal stenosis (narrowing).
  • Perichondritis / Cellulitis.
  • Hearing loss (usually temporary).
  • Malignant (Necrotizing) Otitis Externa: Invasive infection extending to skull base, mainly in elderly diabetics/immunocompromised. Requires urgent referral and IV antibiotics. (Rare)

Prevention

  • Keep ears dry, use earplugs for swimming if prone.
  • Avoid inserting objects (cotton buds) into ear canal.
  • Treat underlying skin conditions.
  • Use acidifying drops (vinegar/alcohol mix) after swimming if prone (controversial).

Patient education

  • Explanation of the condition.
  • Importance of keeping ear dry.
  • Correct technique for instilling ear drops.
  • Avoidance of cotton buds/scratching.
  • Need to complete full course of treatment.
  • Prevention strategies for recurrence.

Uganda-specific notes

Common, especially in humid conditions. Bacterial and fungal causes frequent. Aural toilet is key but suction often unavailable. Chloramphenicol, Gentamicin, Clotrimazole drops often used. Consider underlying HIV.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 21, Section 21.1.3

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