Chronic (Persistent) Otitis Externa

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What is otitis externa?

Otitis externa is an inflammation of the ear canal which may be caused by infection, allergy, or other causes. Symptoms include itch, ear discharge, temporary dulled hearing, and pain.

Most bouts of otitis externa clear within a week or so with ear drops or sprays. These usually contain an antibiotic and a steroid. The antibiotic clears infection and the steroid reduces itch and inflammation.

However, in some cases the otitis externa becomes chronic (persistent) for several weeks or more.

Reasons why otitis externa may become chronic, and possible treatments

Sensitive ears
Some people seem prone to otitis externa. If you get water, shampoo, soap, hair spray, etc, in your ears it may cause irritation or itch. This may cause you to scratch or poke the ear. This can damage the skin in the ear canal and cause inflammation. Inflamed skin can quickly become infected. A vicious circle may then develop. The inflammation and infection cause more itch, you then scratch which makes things worse, etc.

So, despite treatment, the infection may continue if you continue to poke or scratch your ear. Therefore:

• Try not to scratch or poke the ear canal with fingers, cotton wool buds, towels, etc.
• Do not clean the ear canal with cotton buds. They may scratch and irritate, and push wax or dirt further into the ear. The ear cleans itself, and bits of wax will fall out now and then.
• Try not to let soap or shampoo get into your ear canal. You can do this when you have a shower by placing a piece of cotton wool coated in soft white paraffin (eg Vaseline) into the outer ear.
• Do not use corners of towels or cotton buds to dry any water that does get in the ear canal. This will push things further in. Let the ear dry naturally.
• When you swim try to keep your ears dry. You can do this by wearing a tightly fitting cap that covers the ears. Some swimmers use silicone rubber earplugs, but only use them if they do not irritate the skin in your ear canal.

Let the discharge out
As a rule, do not leave balls of cotton wool in the ear canal. This stops the discharge (debris) which needs to come out. However, if the discharge is heavy, you may need to place some cotton wool lightly in the outer part of the canal to mop up the discharge.

If you use cotton wool, replace it frequently with a fresh piece.

Ear drops
Sometimes otitis externa does not clear because ear drops are not used correctly. You have to put them in as often as prescribed to be fully effective. If the drops come out of the ear quickly, they may not work so well. When using drops:

• Lie with the affected ear upwards.
• Put several drops in the ear, and lie in this position for 1-2 minutes.
• Press the cartilage at the front of the ear canal a few times to push the drops deep inside the ear canal.

Resistant bacteria
Some bacteria (germs) which infect the ear canal are resistant to some antibiotic ear drops. A change to a different type of ear drop may be advised if you have used the first one correctly, but there has been little improvement after a week or so.

Sometimes a swab (a small sample of the discharge) is taken and sent to the laboratory. This may help to identify which germ is causing the infection, and which antibiotic is best to use against this germ. If the infection is severe, antibiotic tablets may be needed in addition to drops.

Clearing the discharge may be advised
A doctor or nurse may clean the ear canal. They do this by using cotton wool on the end of a special stick which is gently pushed inside the ear canal to mop up any discharge or debris. Some GPs and nurses are trained to do this. Sometimes a referral to an ear specialist is needed. Sometimes gentle suction or syringing is used to remove discharge lying in the ear canal. You may need a regular clear-out of discharge every few days or so until the otitis externa has gone.

A wick may be advised if the ear canal is very swollen
A wick is a piece of gauze material which is soaked in antibiotic drops. It is gently placed in the ear canal by a doctor or nurse. The wick ensures that an antibiotic is always present and reaches to the inner part of the ear canal. A wick can be changed regularly.

Painkillers
Paracetamol or ibuprofen will usually ease any pain. Stronger painkillers are occassionally needed. If you hold a hot flannel against the ear it may also ease pain.

Still no success?

The above treatments will usually clear most cases of otitis externa. However, a doctor may consider a few other things if it still persists.

Allergy
Some people develop an allergy or sensitivity to ear drops that are used for otitis externa. The itch and discharge may then become worse rather than better. If this is suspected then a change to an ear drop low in allergy reactions may be advised. Sometimes a doctor will advise that you stop all ear drops which contain antibiotics. A steroid-only ear drop may be tried to reduce inflammation.

Referral to a specialist for skin patch testing is sometimes needed to find out what is causing the allergy. For example, the antibiotic, or a preservative in a particular ear drop.

Fungal infections
Most infections of the ear canal are caused by bacteria. These germs usually clear up with antibiotic drops. An uncommon cause of persistent otitis externa is due to a fungal infection. Fungus germs are not killed by antibiotics - in fact antibiotic and steroid ear drops can make a fungal infection worse. A fungal infection may be suspected if an otitis externa does not clear with the usual treatment. A swab may be taken to confirm the diagnosis.

Fungal infections in the ear canal are difficult to treat. It may take several weeks of anti-fungal ear drops and/or tablets to clear a fungal ear infection.

Middle ear infections
If the ear canal is full of discharge it may be difficult for a doctor to tell whether it is from the outer ear (otitis externa) or from a middle ear infection which has come through a burst eardrum. You may be referred to a specialist if the cause is not clear.

Skin disorders
Sometimes the inflammation in the ear canal is a local area of a skin disorder such as a small patch of eczema or psoriasis. The symptoms in the ear may be similar to an infection, but bacteria or fungal germs are not the cause. This is uncommon, but the inflammation in the ear may flare up now and then just as skin disorders flare up from time to time. The treatment which is usually advised is steroid ear drops whenever symptoms flare up.

Referral to a specialist
This may be needed for such things as cleaning the ear canal of discharge, if a fungal infection is suspected, or for a more detailed examination of the ear.

Preventing otitis externa

Otitis externa has a tendency to recur. It is less likely to recur if you follow the advice given above in the section 'sensitive ears'. In short, try to keep the ear canal dry, and avoid soap or shampoo from getting in. The most important thing is to avoid scratching or poking the ear canal with fingers, towels, cotton wool buds, or anything else.

© EMIS and PIP 2006   Updated: June 2006   PRODIGY Validated

The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.

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