Otitis externa is a condition that causes inflammation (redness and swelling) of the external ear canal, which is the tube between the outer ear and eardrum.
Otitis externa is often referred to as "swimmer's ear" because repeated exposure to water can make the ear canal more vulnerable to inflammation.
Symptoms of otitis externa include:
ear pain, which can be severe
itchiness in the ear canal
a discharge of liquid or pus from the ear
some degree of temporary hearing loss
Usually only one ear is affected.
With treatment, these symptoms should clear up within a few days. However, some cases can persist for several months or longer.
When to see your GP
You should see your GP if you think you may have otitis externa.
Your GP will ask you about your symptoms and whether you regularly use any items that are inserted into your ears, such as hearing aids or ear plugs. They may also examine inside your ear using an instrument called an otoscope.
If you have recurring episodes of otitis externa that haven't responded to treatment, your GP may take a swab of the inside of your ear. This will be tested to help determine what type of infection you have, if any, so that appropriate medication can be prescribed.
What causes otitis externa?
Most cases of otitis externa are caused by a bacterial infection, although the condition can also be caused by irritation, fungal infections and allergies.
There are a number of things that can make you more likely to develop otitis externa, including damaging the skin inside your ear and regularly getting water in your ear.
Getting water in your ear is particularly significant because this can cause you to scratch inside your ear, and the moisture also provides an ideal environment for bacteria to grow.
Who is affected?
Otitis externa is relatively common. It is estimated that around 1 in 10 people will be affected by it at some point in their lives.
The condition is slightly more common in women than men and is most often diagnosed in adults aged 45 to 75.
People with certain long-term (chronic) conditions, such as eczema,asthma or allergic rhinitis, are at greater risk of developing the condition.
How otitis externa is treated
Otitis externa does sometimes get better without treatment, but it can take several weeks. Your GP can prescribe ear drop medication that will usually improve the symptoms within a few days.
There are a number of different types of ear drops that may be used to treat otitis externa, but they all tend to be used several times a day for about a week.
Your GP may refer you to a specialist for further treatment and advice if symptoms are severe or they fail to respond to treatment.
Preventing otitis externa
To help reduce your chances of developing otitis externa, you should avoid inserting cotton wool buds and other things into your ears (including your fingers), as this can damage the sensitive skin in your ear canal.
If you are a regular swimmer, consider using ear plugs when swimming or wearing a swimming cap to cover your ears and protect them from water.
You should also try to avoid getting water, soap or shampoo into your ears when you have a shower or bath.
Complications of otitis externa are uncommon, but some can be very serious.
One rare complication of otitis externa is malignant otitis externa, which is where an infection spreads from the ear canal into the surrounding bone.
This requires prompt treatment with antibiotics and sometimes surgery, as it can be fatal if left untreated.
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Earache can be a worrying, but it's usually only caused by a minor infection and will often get better in a few days without treatment
Symptoms of otitis externa
Otitis externa can cause a number of different symptoms affecting the ear and the surrounding area.
Symptoms can include:
itching and irritation in and around your ear canal
redness and swelling of your outer ear and ear canal
a feeling of pressure and fullness inside your ear
scaly skin in and around your ear canal, which may peel off
discharge from your ear, which can be either thin and watery or thick and pus-like
tenderness when you move your ear or jaw
swollen and sore glands in your throat
some hearing loss
Otitis externa sometimes occurs if a hair follicle inside the ear becomes infected by bacteria and develops into a spot (pimple) or boil. If this is the case, you may be able to see the pimple or boil in a mirror. Do not attempt to squeeze any pimples or boils in your ear as this could lead to the infection spreading elsewhere.
In some cases, the symptoms of otitis externa can persist for several months, or sometimes years. This is known as chronic otitis externa.
Symptoms of chronic otitis externa can include:
a constant itch in and around your ear canal
discomfort and pain in your ear that becomes worse when you move it – this is usually much milder than in short-term otitis externa
a thin, watery discharge from your ear
a lack of earwax
a build-up of thick, dry skin in your ear canal, known as stenosis, which can narrow your ear canal and affect your hearing
Causes of otitis externa
There are several different causes of otitis externa, as well as a number of things that make it more likely to occur.
Causes of otitis externa can include:
a bacterial infection – usually by bacteria called Pseudomonas aeruginosa or Staphylococcus aureus
seborrhoeic dermatitis – a common skin condition where the areas of your skin that are naturally greasy become irritated and inflamed, which can sometimes affect the ears
a middle ear infection (otitis media) – discharge produced by an infection deeper in the ear can sometimes lead to otitis externa
a fungal infection – such as from the Aspergillus variety and the Candida albicans variety (which also causes thrush); fungal infections are more common if you use antibacterial or steroid ear drops for a long time
irritation or an allergic reaction – otitis externa can occur because of a reaction to something that comes into contact with your ears, such as ear medication, ear plugs, shampoo or sweat
Otitis externa can also return after previous treatment if you do not complete your course of treatment.
The following things are not direct causes of otitis externa, but they may make the condition more likely to develop.
Swimming (particularly in dirty or polluted water), sweating and being exposed to humid environments can increase your risk of otitis externa because liquid in your ear canal can make you more likely to develop an infection.
Water can wash away earwax inside your ears, which can make them itchy. If you scratch inside your ears, the skin can become damaged, making the external canal more vulnerable to infection. Moisture also provides an ideal environment for bacteria – and to a lesser degree, fungi – to grow.
Your ear canal is very sensitive and can easily become damaged through scratching, excessive cleaning and the insertion of cotton buds. You may also damage it by incorrectly or excessively wearing hearing aids, ear plugs or ear phones.
Your chances of getting otitis externa are increased if you use certain products in or near your ears, such as hair sprays, hair dyes and earwax softeners.
Underlying skin conditions
As well as seborrhoeic dermatitis increasing your risk of otitis externa, underlying skin conditions such as psoriasis, eczema and acne can also increase your chances of developing the condition.
If you have allergic rhinitis or asthma, you may also be at a higher risk of developing otitis externa.
Weak immune system
If you have a condition that can weaken your immune system, such asdiabetes, HIV or AIDS, or if you have been having certain cancer treatments, such as chemotherapy, you may be at higher risk of developing otitis externa.
Treating otitis externa
Otitis externa can usually be treated effectively with ear drops prescribed by your GP and some simple self-care techniques.
In most cases, your symptoms will start to improve within a few days of starting treatment.
If your symptoms are severe or they fail to respond to initial treatment, your GP may refer you to a specialist for further treatment and advice.
Managing your symptoms at home
The advice below should help relieve your symptoms to some extent and help prevent complications:
avoid getting your affected ear wet – wearing a shower cap while showering and bathing can help, but you should avoid swimming until the condition has fully cleared
remove any discharge or debris by gently swabbing your outer ear with cotton wool, being careful not to damage it – don't stick cotton wool or a cotton bud inside your ear
remove anything from your affected ear that may cause an allergic reaction, such as hearing aids, ear plugs and earrings
use painkillers such as paracetamol or ibuprofen to relieve ear pain – these aren't suitable for everyone, so make sure you check the information leaflet that comes with the medication first; if you're still unsure, check with your GP, practice nurse or pharmacist
if your condition is caused by a boil in your ear, placing a warm flannel or cloth over the affected ear can help it heal faster
Treatments your GP can provide
While otitis externa can clear up by itself, this can take several weeks without treatment. Your GP can usually prescribe medicated ear drops that speed up the healing process. These usually need to be taken several times a day for about a week.
There are four main types of ear drops used to treat otitis externa:
antibiotic ear drops – this can treat an underlying bacterial infection
corticosteroid ear drops– this can help reduce swelling
antifungal ear drops– this can treat an underlying fungal infection
acidic ear drops – this can help kill bacteria
Sometimes you may be given medication that's a combination of the above, such as antibiotic and corticosteroid ear drops.
Once treatment is complete and the inflammation has settled, your doctor may want to re-examine your ear to check for any underlying physical problems that could have contributed to the condition, such as having an abnormal or perforated (torn) ear drum.
Applying ear drops
Ear drops may not work as well if they are not used in the right way, so it's important to apply them correctly. Ideally, ask somebody else to apply the drops for you as this makes the process much easier.
You (or your helper) will need to follow these steps:
gently remove any discharge, earwax or debris from your outer ear using a twist of cotton wool
warm the ear drops by holding them in your hands for a few minutes, as cold ear drops can make you feel dizzy
lie on your side with your affected ear facing up before applying the drops directly into your external ear canal
gently push and pull your ear for about 30 seconds to work the drops in and get any trapped air out
stay lying down for three to five minutes to ensure that the ear drops do not come out of your ear canal
leave the ear canal open to dry
If necessary, there are some other treatments your GP can provide to help treat otitis externa, such as:
stronger prescription painkillers such as codeine for severe cases
antibiotic tablets or capsules to treat a severe infection – an antibiotic called flucloxacillin is usually the preferred choice
treatment for underlying skin conditions that may aggravate your otitis externa, such as seborrhoeic dermatitis, psoriasis or eczema
if a boil develops inside your ear, your GP may decide to pierce it with a sterile needle and drain the pus – this is known as incision and drainage, and you should not attempt to do it yourself
If necessary, your GP may refer you to a specialist for further treatment.
The specialist may decide to remove earwax from inside your ears to help make ear drops more effective. This can be done in a number of ways:
syringing or irrigation –where water is injected through the nozzle of a syringe into the ear canal to dislodge and wash away any earwax
microsuction – where a small suction device is used to remove any earwax, discharge and debris from your outer ear and ear canal
dry swabbing – this gently mops out earwax from your ear canal
You may also need an ear wick, which is a soft cotton gauze plug covered with medication and inserted into your ear canal.
An ear wick allows the medication to reach the end of your ear canal. It should be changed every two to three days.
Complications of otitis externa
Although complications associated with otitis externa are uncommon, there is a small risk of further problems developing.
Some of the main complications of otitis externa are described below.
Abscesses are painful, pus-filled growths that can form in and around the affected ear after an infection. They usually heal on their own, but in some cases your GP may need to drain the pus from them.
Narrowing of the ear canal
If you have long-term (chronic) otitis externa, thick and dry skin can build up inside your ear canal.
This causes the ear canal to narrow (stenosis), which may affect your hearing and can even cause deafness in rare cases. However, it can usually be treated with ear drops.
Inflamed or perforated eardrum
It is possible for any infection to spread to your eardrum. In some cases, the infection may cause pus to build up inside your inner ear and may rupture (tear) your eardrum. This is known as a perforated eardrum.
temporary hearing loss
earache or discomfort
a discharge of mucus from your ear
ringing or buzzing in your ear (tinnitus)
In many cases, a perforated eardrum will heal without treatment in a couple of months. Surgery may be recommended if it shows no signs of healing after this time.
Cellulitis is a bacterial skin infection that can occur after otitis externa. It's when bacteria that normally live harmlessly on the surface of your skin enter your skin's deeper layers through damaged areas, such as those caused by otitis externa.
Cellulitis causes affected areas of skin to become red, painful, hot and tender to the touch.
Other symptoms include:
a general sense of feeling unwell
Most cases of cellulitis can be treated with a seven-day course ofantibiotics.
If cellulitis occurs in a person who was already very ill or who is very vulnerable to the effects of infection, they may need to be admitted to hospital as a precaution.
Malignant otitis externa
Malignant otitis externa is a serious but rare complication of otitis externa where the infection spreads to the bone that surrounds your ear canal.
It usually affects adults more than children. Adults who have a weakened immune system are at a particularly increased risk of developing it. This includes people having chemotherapy or who have certain long-term health conditions, such as diabetes or HIV.
There were 810 cases of malignant otitis externa seen in hospitals in England between 2012 and 2013. More than 700 of these were diagnosed in people who were 60 or older.
Signs and symptoms of malignant otitis externa can include:
severe ear pain and headaches
exposed bone visible in your ear canal
facial nerve palsy, where your face droops on the side of the affected ear
Without treatment, malignant otitis externa can be fatal. However, it can be effectively treated using antibiotics and surgery to remove any damaged tissue.
Preventing otitis externa
It's not always possible to prevent otitis externa, but there are several things you can do to reduce your risk of developing the condition.
These are described below.
Avoid damaging your ears
Don't insert cotton wool buds or other objects into your ears. Wax works its way out naturally and cotton buds should only be used to sweep around your outer ear.
If earwax build-up is a problem, have it removed by a healthcare professional.
Keep your ears dry and clean
Try not to let water, soap or shampoo get inside your ears when you wash them. Wear a shower cap while you shower or bathe if you don't intend to wash your hair.
After washing, dry your ears using a hairdryer on a low setting. Never push the corners of a towel into your ears to dry them as this can cause damage.
If you swim regularly, wear a swimming hat that covers your ears or use ear plugs (but make sure you insert them carefully and don't use them if they irritate your ears).
Treat and prevent other skin conditions
If you develop otitis externa and you have allergies, tell your GP or practice nurse. Ear drops that contain certain substances, such as neomycin, are more likely to cause an allergic reaction. Your GP, practice nurse or pharmacist can advise you about which ear drops are most suitable for you.
If you have an allergic reaction to anything that is placed inside your ears, such as hearing aids, earplugs or earrings, remove the item. A mild allergic reaction will usually clear up on its own. Using hypoallergenic products (products that have a lower potential for causing allergic reactions) may also help.
Seek medical advice for any other skin conditions, such as psoriasis or eczema, so they can be treated using the right medication.
Try using acidifying ear drops or spray to help keep your ears clean, particularly before and after swimming. These are available without a prescription in most pharmacies and may help prevent otitis externa recurring.