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Diseases

Otitis externa

OVERVIEW

  • Highlights & Basics
  • Images

DIAGNOSIS

  • Diagnostic Approach
  • Risk Factors
  • History & Exam
  • Tests
  • Differential Diagnosis
  • Criteria
  • Screening

TREATMENT

  • Tx Approach
  • Tx Options
  • Emerging Tx
  • Prevention

FOLLOW-UP

  • Overview
  • Complications

REFERENCES

  • Citations
  • Guidelines
  • Credits

PATIENT RESOURCES

  • Patient Instructions

Highlights & Basics

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Key Highlights
  • Acute otitis externa (AOE) is a diffuse inflammation of the external ear canal that is most commonly caused by Pseudomonas aeruginosa and Staphylococcus aureus.

  • Presents with rapid onset of ear pain, tenderness, itching, aural fullness, and hearing loss.

  • More common in children and young adults.

  • Fungal otitis externa is a fungal infection of the external ear caused by molds and yeasts, which presents in a similar way to acute bacterial otitis externa.

  • Necrotizing otitis externa infection (also called malignant otitis externa) involves skin and soft tissue of the external auditory canal and bone tissue of the temporal bone.

Quick Reference

  • History & Exam

    • Key Factors

      • Other Factors

        More information...
      • Diagnostics Tests

          More information...
        • Treatment Options

            More information...

          Definition

          Epidemiology

          Etiology

          Pathophysiology

          content by BMJ Group
          Last updated

          Images

          • Diagram of acute otitis externa

            Diagram of acute otitis externa

          • Swollen ear canal, almost completely closed due to acute otitis externa

            Swollen ear canal, almost completely closed due to acute otitis externa

          • ​White purulent debris can be seen at the external auditory meatus

            ​White purulent debris can be seen at the external auditory meatus

          • ​The ear canal is narrowed, making it appear more slit-like, with white debris sitting on the canal

            ​The ear canal is narrowed, making it appear more slit-like, with white debris sitting on the canal wall

          Citations

            Key Articles

            • Rosenfeld RM, Schwartz SR, Cannon CR, et al. American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014 Feb;150(1 suppl):S1-24. [Erratum in: Otolaryngol Head Neck Surg. 2014 Mar;150(3):504].[Abstract][Full Text]

            • Jackson EA, Geer K. Acute otitis externa: rapid evidence review. Am Fam Physician. 2023 Feb;107(2):145-51.[Abstract]

            Referenced Articles

            • 1. Rosenfeld RM, Schwartz SR, Cannon CR, et al. American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014 Feb;150(1 suppl):S1-24. [Erratum in: Otolaryngol Head Neck Surg. 2014 Mar;150(3):504].[Abstract][Full Text]

            • 2. Browning GG. Aetiopathology of inflammatory conditions of the external and middle ear. In: Kerr AG, ed. Scott-Brown's Otolaryngology. Oxford, UK: Butterworth-Heinemann; 1997. 

            • 3. Hirsch BE. Infections of the external ear. Am J Otolaryngol. 1992 May-Jun;13(3):145-55.[Abstract]

            • 4. Lee SK, Lee SA, Seon SW, et al. Analysis of prognostic factors in malignant external otitis. Clin Exp Otorhinolaryngol. 2017 Sep;10(3):228-35.[Abstract][Full Text]

            • 5. Walshe P, Cleary M, McConn WR, et al. Malignant otitis externa: a high index of suspicion is still needed for diagnosis. Irish Med J. 2002 Jan;95(1):14-6.[Abstract]

            • 6. Johnson AK, Batra PS. Central skull base osteomyelitis: an emerging clinical entity. Laryngoscope. 2014 May;124(5):1083-7.[Abstract]

            • 7. Frost J, Samson AD. Standardised treatment protocol for necrotizing otitis externa: retrospective case series and systematic literature review. J Glob Antimicrob Resist. 2021 Sep;26:266-71.[Abstract][Full Text]

            • 8. Kiakojuri K, Mahdavi Omran S, Roodgari S, et al. Molecular identification and antifungal susceptibility of yeasts and molds isolated from patients with otomycosis. Mycopathologia. 2021 May;186(2):245-57.[Abstract]

            • 9. Aboutalebian S, Ahmadikia K, Fakhim H, et al. Direct detection and identification of the most common bacteria and fungi causing otitis externa by a stepwise multiplex PCR. Front Cell Infect Microbiol. 2021;11:644060.[Abstract][Full Text]

            • 10. Koltsidopoulos P, Skoulakis C. Otomycosis with tympanic membrane perforation: a review of the literature. Ear Nose Throat J. 2020 Sep;99(8):518-21.[Abstract][Full Text]

            • 11. Alshahni MM, Alshahni RZ, Fujisaki R, et al. A case of topical ofloxacin-induced otomycosis and literature review. Mycopathologia. 2021 Dec;186(6):871-6.[Abstract]

            • 12. Jackson EA, Geer K. Acute otitis externa: rapid evidence review. Am Fam Physician. 2023 Feb;107(2):145-51.[Abstract]

            • 13. Selesnick SH. Otitis externa: management of the recalcitrant case. Am J Otology. 1994 May;15(3):408-12.[Abstract]

            • 14. Roland PS, Stroman DW. Microbiology of acute otitis externa. Laryngoscope. 2002 Jul;112(7 Pt 1):1166-77.[Abstract]

            • 15. Rowlands S, Devalia H, Smith C, et al. Otitis externa in UK general practice: a survey using the UK General Practice Research Database. Br J Gen Pract. 2001 Jul;51(468):533-8.[Abstract][Full Text]

            • 16. Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician. 2012 Dec 1;86(11):1055-61.[Abstract][Full Text]

            • 17. Livingstone DM, Smith KA, Lange B. Scuba diving and otology: a systematic review with recommendations on diagnosis, treatment and post-operative care. Diving Hyperb Med. 2017 Jun;47(2):97-109.[Abstract]

            • 18. Barry V, Bhamra N, Balai E, et al. Otitis externa. BMJ. 2021 Mar 31;372:n714.[Abstract][Full Text]

            • 19. Schwartz SR, Magit AE, Rosenfeld RM, et al. Clinical practice guideline (update): earwax (cerumen impaction). Otolaryngol Head Neck Surg. 2017 Jan;156(1_suppl):S1-29.[Abstract][Full Text]

            • 20. American College of Radiology. ​ACR appropriateness criteria: inflammatory ear disease. 2024 [internet publication].​[Full Text]

            • 21. Moss WJ, Finegersh A, Narayanan A, et al. Meta-analysis does not support routine traditional nuclear medicine studies for malignant otitis. Laryngoscope. 2020 Jul;130(7):1812-6.[Abstract]

            • 22. Stern Shavit S, Bernstine H, Sopov V, et al. FDG-PET/CT for diagnosis and follow-up of necrotizing (malignant) external otitis. Laryngoscope. 2019 Apr;129(4):961-6.[Abstract]

            • 23. Hodgson SH, Khan MM, Patrick-Smith M, et al. UK consensus definitions for necrotising otitis externa: a Delphi study. BMJ Open. 2023 Feb 20;13(2):e061349.[Abstract][Full Text]

            • 24. Chan KL, Soo G, van Hasselt CA. Furunculosis. Ear Nose Throat J. 1997 Mar;76(3):126.[Abstract]

            • 25. Dubach P, Mantokoudis G, Caversaccio M. Ear canal cholesteatoma: meta-analysis of clinical characteristics with update on classification, staging and treatment. Curr Opin Otolaryngol Head Neck Surg. 2010 Oct;18(5):369-76.[Abstract]

            • 26. Leung DY, Boguniewicz M, Howell MD, et al. New insights into atopic dermatitis. J Clin Invest. 2004 Mar;113(5):651-7.[Abstract][Full Text]

            • 27. Clark GW, Pope SM, Jaboori KA. Diagnosis and treatment of seborrheic dermatitis. Am Fam Physician. 2015 Feb 1;91(3):185-90.[Abstract][Full Text]

            • 28. List T, Jensen RH. Temporomandibular disorders: old ideas and new concepts. Cephalalgia. 2017 Jun;37(7):692-704.[Abstract][Full Text]

            • 29. Durham J, Newton-John TR, Zakrzewska JM. Temporomandibular disorders. BMJ. 2015 Mar 12;350:h1154.[Abstract][Full Text]

            • 30. Hui CP; Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Acute otitis externa. Paediatr Child Health. 2013 Feb;18(2):96-101.[Abstract][Full Text]

            • 31. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD004740.[Abstract][Full Text]

            • 32. Kantas I, Balatsouras DG, Vafiadis M, et al. The use of trichloroacetic acid in the treatment of acute external otitis. Eur Arch Otorhinolaryngol. 2007 Jan;264(1):9-14.[Abstract]

            • 33. Dohar JE. Evolution of management approaches for otitis externa. Pediatr Infect Dis J. 2003 Apr;22(4):299-305;quiz 306-8.[Abstract]

            • 34. van Balen FA, Smit WM, Zuithoff NP, et al. Clinical efficacy of three common treatments in acute otitis externa in primary care: randomised controlled trial. BMJ. 2003 Nov 22;327(7425):1201-5.[Abstract][Full Text]

            • 35. Lambert IJ. A comparison of the treatment of otitis externa with "Otosporin" and aluminium acetate: a report from a services practice in Cyprus. J R Coll Gen Pract. 1981 May;31(226):291-4.[Abstract][Full Text]

            • 36. Mösges R, Schröder T, Baues CM, et al. Dexamethasone phosphate in antibiotic ear drops for the treatment of acute bacterial otitis externa. Curr Med Res Opin. 2008 Aug;24(8):2339-47.[Abstract]

            • 37. Pistorius B, Westberry K, Drehobl M, et al. Prospective, randomized, comparative trial of ciprofloxacin otic drops, with or without hydrocortisone, vs. polymyxin B-neomycin-hydrocortisone otic suspension in the treatment of acute diffuse otitis externa. Infect Dis Clin Pract. 1999;8:387-95.

            • 38. Jones RN, Milazzo J, Seidlin M. Ofloxacin otic solution for treatment of otitis externa in children and adults. Arch Otolaryngol Head Neck Surg. 1997 Nov;123(11):1193-200.[Abstract]

            • 39. Wall GM, Stroman DW, Roland PS, et al. Ciprofloxacin 0.3%/dexamethasone 0.1% sterile otic suspension for the topical treatment of ear infections: a review of the literature. Pediatr Infect Dis J. 2009 Feb;28(2):141-4.[Abstract]

            • 40. Mösges R, Nematian-Samani M, Hellmich M, et al. A meta-analysis of the efficacy of quinolone containing otics in comparison to antibiotic-steroid combination drugs in the local treatment of otitis externa. Curr Med Res Opin. 2011 Oct;27(10):2053-60.[Abstract]

            • 41. Wang X, Winterstein AG, Alrwisan A, et al. Risk for tympanic membrane perforation after quinolone ear drops for acute otitis externa. Clin Infect Dis. 2020 Mar 3;70(6):1103-9. [Abstract][Full Text]

            • 42. Rahman A, Rizwan S, Waycaster C, et al. Pooled analysis of two clinical trials comparing the clinical outcomes of topical ciprofloxacin/dexamethasone otic suspension and polymyxin B/neomycin/hydrocortisone otic suspension for the treatment of acute otitis externa in adults and children. Clin Ther. 2007 Sep;29(9):1950-6.[Abstract]

            • 43. Roland PS, Belcher BP, Bettis R, et al; Cipro HC Study Group. A single topical agent is clinically equivalent to the combination of topical and oral antibiotic treatment for otitis externa. Am J Otolaryngol. 2008 Jul-Aug;29(4):255-61.[Abstract]

            • 44. Hannley MT, Denneny JC 3rd, Holzer SS. Use of ototopical antibiotics in treating 3 common ear diseases. Otolaryngol Head Neck Surg. 2000 Jun;122(6):934-40.[Abstract]

            • 45. Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804.[Abstract][Full Text]

            • 46. Hopkins ME, Bennett A, Henderson N, et al. A retrospective review and multi-specialty, evidence-based guideline for the management of necrotising otitis externa. J Laryngol Otol. 2020 Jun;134(6):487-92.[Abstract]

            • 47. Carfrae MJ, Kesser BW. Malignant otitis externa. Otolaryngol Clin North Am. 2008 Jun;41(3):537-49;viii-ix.[Abstract]

            • 48. Bernstein JM, Holland NJ, Porter GC, et al. Resistance of Pseudomonas to ciprofloxacin: implications for the treatment of malignant otitis externa. J Laryngol Otol. 2007 Feb;121(2):118-23.[Abstract]

            • 49. Sreepada GS, Kwartler JA. Skull base osteomyelitis secondary to malignant otitis externa. Curr Opin Otolaryngol Head Neck Surg. 2003 Oct;11(5):316-23.[Abstract]

            • 50. Franco-Vidal V, Blanchet H, Bebear C, et al. Necrotizing external otitis: a report of 46 cases. Otol Neurotol. 2007 Sep;28(6):771-3.[Abstract]

            • 51. Amaro CE, Espiney R, Radu L, et al. Malignant (necrotizing) externa otitis: the experience of a single hyperbaric centre. Eur Arch Otorhinolaryngol. 2019 Jul;276(7):1881-7.[Abstract]

            • 52. Phillips JS, Jones SE. Hyperbaric oxygen as an adjuvant treatment for malignant otitis externa. Cochrane Database Syst Rev. 2013 May 31;(5):CD004617.[Abstract][Full Text]

            • 53. Hajioff D, Mackeith S. Otitis externa. BMJ Clin Evid. 2010 Aug 3;2010:0510.[Abstract][Full Text]

            • 54. Martin TJ, Kerschner JE, Flanary VA. Fungal causes of otitis externa and tympanostomy tube otorrhea. Int J Pediatr Otorhinolaryngol. 2005 Nov;69(11):1503-8.[Abstract]

            • 55. Mion M, Bovo R, Marchese-Ragona R, et al. Outcome predictors of treatment effectiveness for fungal malignant external otitis: a systematic review. Acta Otorhinolaryngol Ital. 2015 Oct;35(5):307-13.[Abstract][Full Text]

            • 56. Abou-Halawa AS, Khan MA, Alrobaee AA, et al. Otomycosis with perforated tympanic membrane: self medication with topical antifungal solution versus medicated ear wick. Int J Health Sci (Qassim). 2012 Jan;6(1):73-7.[Abstract][Full Text]

            • 57. Görür K, İsmi O, Özcan C, et al. Treatment of otomycosis in ears with tympanic membrane perforation is easier with paper patch. Turk Arch Otorhinolaryngol. 2019 Dec;57(4):182-6.[Abstract][Full Text]

            • 58. Demir D, Yılmaz MS, Güven M, et al. Comparison of clinical outcomes of three different packing materials in the treatment of severe acute otitis externa. J Laryngol Otol. 2018 Jun 13;132(6):523-8.[Abstract]

            • 59. US Food and Drug Administration. FDA drug safety communication: FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older. January 2018 [internet publication].[Full Text]

            • 60. Hadland SE, Agarwal R, Raman SR, et al. Opioid prescribing for acute pain management in children and adolescents in outpatient settings: clinical practice guideline. Pediatrics. 2024 Sep 30:e2024068752.[Abstract][Full Text]

            • 61. Medicines and Healthcare products Regulatory Agency. Codeine: restricted use as analgesic in children and adolescents after European safety review. Drug Safety Update. December 2014 [internet publication].[Full Text]

            • 62. European Medicines Agency. Restrictions on use of codeine for pain relief in children - CMDh endorses PRAC recommendation. June 2013 [internet publication].[Full Text]

            • 63. Ali T, Meade K, Anari S, et al. Malignant otitis externa: case series. J Laryngol Otol. 2010 Aug;124(8):846-51.[Abstract]

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