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Key Features

Essentials of Diagnosis

  • Rapid onset of symptoms in the past 3 weeks and

  • Symptoms of ear canal inflammation, including otalgia, itching, or fullness, with or without hearing loss or jaw pain and

  • Signs of ear canal inflammation, including tenderness of the tragus and/or pinna, ear canal edema and/or erythema, otorrhea, regional lymphadenitis, tympanic membrane (TM) erythema, or cellulitis of the pinna and adjacent skin

General Considerations

  • Defined as a cellulitis of the soft tissues of the external auditory canal, which can extend to surrounding structures such as the pinna, tragus, and lymph nodes

  • Humidity, heat, and moisture in the ear are known to contribute to the development of otitis externa, along with localized trauma to the ear canal skin

  • Most common organisms are Staphylococcus aureus and Pseudomonas aeruginosa

Clinical Findings

  • Acute onset of pain

  • Aural fullness

  • Decreased hearing

  • Itching in the ear

  • Manipulation of the pinna or tragus causes considerable pain

  • Discharge may start out as clear then become purulent and may also cause secondary eczema of the auricle

  • Ear canal is typically swollen and narrowed, and the patient may resist any attempt to insert an otoscope

  • Debris is present in the canal, and it is usually very difficult to visualize the TM due to canal edema

Differential Diagnosis

  • Acute otitis media with TM rupture

  • Furunculosis of the ear canal

  • Herpes zoster oticus

  • Mastoiditis


  • Clinical


  • Pain control, removal of debris from the canal, topical antimicrobial therapy, and avoidance of causative factors

  • Fluoroquinolone eardrops are first-line therapy

  • If the ear canal is too edematous to allow entry of the eardrops, a Pope ear wick (expandable sponge) should be placed to ensure antibiotic delivery

  • Oral antibiotics are indicated for any signs of invasive infection, such as fever, cellulitis of the face or auricle, or tender periauricular or cervical lymphadenopathy

  • In such cases, in addition to the ototopical therapy, cultures of the ear canal discharge should be sent, and an antistaphylococcal antibiotic prescribed while awaiting culture results



  • If untreated, facial cellulitis may result

  • Malignant otitis externa

    • Can develop in immunocompromised persons

    • Infection spreads to the skull base with resultant osteomyelitis

    • Life-threatening and should be evaluated with a fine-cut temporal bone CT scan


Kaushik  V, Malik  T, Saeed  SR: Interventions for acute otitis externa. Cochrane Database Syst Rev 2010;(1):CD004740
[PubMed: 20091565] .
Rosenfeld  RM, Schwartz  SR, Cannon  CR  et al: Clinical practice guideline: acute otitis externa executive summary. Otolaryngol Head Neck Surg 2014 Nov;150(2):161–168
[PubMed: 24492208] .
Waitzman  AA  et al: Otitis externa:

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