Definition and Frequency
The outer ear canal is the passage between the outer ear (auricle) and the eardrum. Inflammation of this area is called otitis externa and is often popularly known as “swimmer’s ear”, because swimming or frequent contact with water is one of the most important factors that make the condition more likely to develop. Outer ear canal infections are among the leading reasons for visits to ENT outpatient clinics, especially in the hot and humid months. Otomycosis, a special subtype of this infection, is an infection of the outer ear canal with fungi (usually Aspergillus or Candida species) and can follow a more stubborn course than bacterial infections.
Otitis externa can be classified into two forms: acute (sudden in onset and short-lived) and chronic (long-standing or frequently recurring). Acute bacterial otitis externa is the most common form and is usually associated with bacteria such as Pseudomonas aeruginosa and Staphylococcus aureus. Chronic otitis externa, on the other hand, is a condition lasting weeks to months, with recurrent itching and mild discharge, which mostly develops on a background of allergy or eczema. Otomycosis is seen more often in humid and hot climates, after prolonged use of antibiotic ear drops, or in people with weakened immunity.
Symptoms
Typical symptoms of outer ear canal infection include ear pain, a feeling of fullness in the ear, itching and discharge. A distinguishing finding is that the pain increases markedly when the outer ear or the tragus (the small projection in front of the ear) is touched or pulled; unlike middle ear infection, this feature points to an outer ear canal infection. In advanced cases the ear canal can swell shut completely and cause reduced hearing. In otomycosis, the most prominent finding is persistent, intense itching; the discharge may look whitish-grey or black-speckled, which reflects the presence of fungal spores. In otomycosis, pain is usually milder than in bacterial infection, but itching is much more pronounced.
In severe cases, redness and swelling around the outer ear, pain that increases with jaw movements, and enlarged lymph nodes in front of and behind the ear may be seen. As the infection progresses, the ear canal may close completely; in this case both the pain and the hearing loss become pronounced. Rarely, especially in patients with diabetes or a suppressed immune system, the infection can spread to the surrounding bone and soft tissues and cause serious findings such as severe headache and facial paralysis; this condition requires urgent evaluation.
Causes and Risk Factors
The most important risk factor for outer ear canal infection is damage to the integrity of the skin of the ear canal. Cleaning earwax with cotton swabs, or poking at the ear with fingers or other objects, creates micro-scratches in the skin of the ear canal and paves the way for bacteria and fungi to settle. Frequent swimming, moisture left in the ear after showering, and prolonged use of earphones or hearing aids increase the risk of infection by disturbing the ear canal’s natural acid–base balance and its protective layer of earwax. Hot and humid climates, systemic diseases that affect immunity such as diabetes, and prolonged use of antibiotics or corticosteroids are additional factors that predispose especially to otomycosis.
The use of ear protectors or ear jewelry, and contact of chemicals such as hair dye and shampoo with the ear canal, can pave the way for outer ear canal infection through allergic contact dermatitis. In people with skin conditions such as eczema or psoriasis, the skin of the ear canal can also be affected, so otitis externa may be more frequent and more stubborn in this group of patients. Chlorine in pool water can dry out and irritate the skin of the ear canal and weaken its barrier function; for this reason, protective earplugs are recommended for regular swimmers.
The Diagnostic Process
The diagnosis is made from the patient’s history and otoscopic examination. The ear canal looks red, swollen and tender, and the pain increases markedly on touch. The color, consistency and smell of the discharge help with the diagnosis: yellow-greenish discharge suggests a bacterial infection, while whitish-grey or black-speckled discharge suggests a fungal infection. Detailed examination of the ear canal under the microscope is important both for making the diagnosis and for assessing the condition of the eardrum. In doubtful or treatment-resistant cases, a culture can be taken from the discharge to identify the causative microorganism. In recurrent or severe cases, it may be necessary to look for underlying systemic conditions such as diabetes.
In the differential diagnosis, assessing the integrity of the eardrum is very important, because if the eardrum is perforated, the use of some drop formulations may be restricted owing to the risk of them passing into the middle ear. In chronic or treatment-resistant otitis externa, it may be necessary to rule out conditions such as underlying allergic contact dermatitis, eczema or, rarely, tumors of the ear canal. In patients with diabetes, severe pain, headache and the appearance of granulation tissue (excess tissue growth) in the ear canal may herald a severe infection spreading to bone (malignant otitis externa), so imaging should be added.
Treatment Options
Conservative Treatment
The first and most important step of treatment is careful cleaning of the ear canal under the microscope; this removes discharge and debris and also ensures that the drops used afterwards reach every part of the ear canal. After cleaning, antibiotic ear drops, combined with a corticosteroid if necessary, are used for bacterial infections, and antifungal drops or solutions for otomycosis. Keeping the ear dry and avoiding contact with water throughout treatment is one of the most critical elements of healing. Painkillers can be added for severe pain; if the ear canal is so swollen that it is completely blocked, a special ear wick may be placed temporarily so that the drops can reach the canal.
Surgical Treatment
Outer ear canal infection and otomycosis are, in the great majority of cases, conditions that do not require surgery and heal with medical treatment. However, surgical debridement or surgery to widen the ear canal may be needed in chronic, treatment-resistant cases in which recurrent infections have caused permanent narrowing (stenosis) of the ear canal, or in rare severe infections that spread to bone (malignant otitis externa). Because such advanced cases can occur particularly in patients with diabetes or a suppressed immune system, close follow-up is important in this group.
Recovery and Follow-up
With appropriate treatment, outer ear canal infection usually improves markedly within 7–10 days; because otomycosis can be stubborn, its treatment may take somewhat longer, and it may take time for the itching to disappear completely. Stopping treatment before it is completed can cause the infection to recur or become chronic. During recovery, it is recommended not to let water into the ear, to avoid swimming and to protect the ear in the shower. In patients with recurrent infections, giving up cotton swabs and having the ears cleaned at the doctor’s office are the most effective ways to prevent recurrence. If symptoms do not improve within 2 weeks despite treatment, a follow-up examination and, if necessary, a culture test are recommended.
Applying the drops correctly directly affects how quickly the ear heals; for the drops to reach the ear canal fully, it is recommended to tilt the head to the side, put in the drops and then stay in that position for a few minutes. Itching that continues for a long time despite treatment may indicate an underlying allergic background or an eczema-like skin problem, and in that case the treatment plan is reviewed accordingly. In patients with diabetes and people with weakened immunity, recovery should be monitored more closely, and medical attention should be sought immediately if the pain increases or new findings such as headache appear.
Frequently Asked Questions
Water got into my ear but I have no symptoms. Should I take precautions? Gently drying the ear from the outside after water has got in is usually enough; if there are no symptoms, no further treatment may be needed, but protective earplugs are recommended for people who are often in contact with water.
Can I keep swimming? Because the ear must stay dry during treatment, it is recommended to avoid swimming and letting water into the ear.
Why is otomycosis so stubborn? Because the spores settle into the skin of the ear canal and multiply easily in a moist environment, fungal infections may need longer treatment than bacterial infections.
My ear pain gets worse when I touch my ear. What does this mean? Pain that increases when the tragus or the outer ear is touched is a typical finding of outer ear canal infection.
Can cleaning with cotton swabs cause this condition? Yes, cotton swabs can create micro-scratches in the skin of the ear canal and make it easier for bacteria and fungi to settle.
What can I do to keep my ear dry? A protector that stops water getting into the ear can be used in the shower; after swimming, the ear should be dried gently from the outside, and cotton swabs should not be used.
For the summary:
Back to the short articleThis article is for general information purposes only; please consult your physician for diagnosis and treatment.