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In general terms otitis externa (commonly called  swimmers ear) is an inflammation of the skin of the auditory canal.
In order to understand otitis externa, understanding the anatomy and physiology of the external auditory canal is important. The external auditory canal is comprised of cartilaginous and bony segments.  The skin covering the external cartilaginous component is thick, hair bearing and produces cerumen (wax), with cerumen acting as both a waterproofing  as well as an antibacterial and antifungal agent. Note the severe swelling causing occlusion of the external auditory canal, with only a minimal degree of discharge seen. Fungi are responsible for approximately 10% of cases with Aspergillus species the most prominent.
Post treatment fungal colonisation and chronic fungal otitis externa are not uncommon entities. Correct diagnosis: especially in children there is a often a difficulty in determining whether a presentation of otalgia is the result of otitis externa or of the more common acute otitis media, especially if this is associated with a tympanic membrane perforation. Ear toilet: the commonest cause of treatment failure is inability to apply topical therapy. Severe swelling of the canal: Oral antibiotics and a short course oral steroids can allow initial resolution of swelling then allowing topical therapy to be more effective. Referral for microscopic toilet: this allows effective removal of debris and purulent discharge. Insertion of a wick: a self expanding wick inserted into a narrowed canal allows delivery of topical therapy with continuous exposure to the antimicrobial agent. Malignant otitis externa (skull base osteomyelitis): essentially isolated to the immunocompromised.
Water precautions: for those prone to recurrent infections the use of cotton wool with Vaseline in the bath and shower, and fitted ear plugs for swimming. Simple intermittent use of olive oil drops can be very useful for minimising wax buildup, dryness and itching.
All information and advice on this website is of a general nature and may not apply to you. We can’t tell whether a discharging ear is simply otitis externa, or a more deep seated problem like cholesteatoma, until the whole of the eardrum has been seen. In established otitis externa, dead skin and infected material should be removed to give medications a proper chance to work. The eardrum is a paper-thin membrane, shaped like a miniature satellite dish, 8-10 mm diameter. The vibrations are transmitted to the inner ear via three small bones (ossicles) suspended in the middle ear. The inner ear acts like a microphone, turning sound vibrations into electrical signals which are sent to the brain in the nerve of hearing. For this to occur, the middle ear must contain air at the same atmospheric pressure as the outer ear.
If you paint a dot of ink in the middle of someone’s eardrum, then go back a week later and look at it, it will have moved toward the edge. Ear canal skin grows in such a way that the outer layers are slowly moved outwards, like a conveyor belt. In otitis externa, the conveyor belt either stops, or doesn’t go fast enough to cope with the increased rate of turnover of skin cells. Sometimes, otitis externa is due to more deep seated disease affecting the middle ear or inner ear.
Occasionally, otitis externa will first come to medical attention as a result of complications from the more serious disease. The reaction of the skin to the infection may result in a vicious circle of inflammation, swelling, shedding of dead skin which provides food for the germs. This unusual condition, thought to be caused by swimming in cold water in childhood, predisposes to otitis externa.
Sometimes, otitis externa is the presenting sign of a more severe disease affecting the middle ear or inner ear.
Sudden onset of severe vertigo may be due to the disease eroding into the lateral semicircular canal of the inner ear. The mycelium (my-seal-ee-um) is the mat of fine white wispy fibres, rather like cotton wool. Until otitis externa has been treated, it is impossible to know if we are dealing with an underlying middle ear condition such as cholesteatoma, because the eardrum is not visible.
Taking a swab, and sending it to the microbiology lab for conventional microscopy, culture and sensitivity is of very limited value in otitis externa.
Swab-taking and antibiotic prescription does not help much in a biofilm disease like otitis externa. When several different germs grow from one swab, deciding between culprits and innocent bystanders is a matter of judgement.
The reason antibiotics don’t always help much is because otitis externa is much more than a simple infection.
If you are prescribed ear drops, make sure you use them properly, otherwise they probably won’t work.
You then massage the tragus (the piece of skin that sticks out just in front of the ear canal like an open trapdoor) to force the drops right down to the eardrum.
Microsuction is an examination and treatment of the ear using a high powered binocular operating microscope.
It usually causes some short lived vertigo (dizzines), lasting no more than a minute or so.
An alternative to microsuction often used in children with runny, discharging ears is to gently mop out the ear with a cotton wool applicator. If we can’t carry out an adequate examination with the child (or adult) awake, a General Anaesthetic may be recommended. Pope wick held in crocodile forceps ready to be placed in a swollen narrow ear canal to treat otitis externa. Sometimes, and especially in fungal cases, an ointment based dressing is the most useful method of treatment. The worst kind of water is bath water – it contains germs from the rest of the body and irritant soap. Plug your ears with cotton wool balls rolled in Vaseline® to provide a waterproof seal when showering or hair washing. A neoprene headband such as the Ear Band-it® will help stop the ear plugs from falling out.
If you have a long term problem with otitis externa, and want to swim, you may prefer to buy a custom made ear mold from an audiologist. Never poke anything down your ear canal – the skin is very delicate and easily damaged.
Many otitis externa patients find that they can’t wear hearing aids because they cause infection, with painful, discharging ears. Some audiologists try to get around the problem of blockage by using loose fitting or vented moulds. A bone conductor hearing aid uses bone conduction to put sound directly into the inner ear, bypassing the middle ear problem. En los ninos y debido a los banos en piscinas, rios, playas y demas actividades veraniegas, se produce con mas frecuencia la Otitis Infantil Externa, tambien llamada “ Otitis del nadador ”.
Es una infeccion de la piel del conducto auditivo externo, no guarda relacion con la otitis que se produce con los resfriados (Otitis Media) que se produce en otra region del oido. Al pasar los ninos mucho tiempo en el agua, se acumula mucha humedad en el oido, el conducto auditivo se puede irritar, lesionando la piel y facilitando que se infecte. Suele empezar con picor de oido, aunque el sintoma principal es el dolor, que puede llegar a ser intenso y aumenta cuando se tira levemente de la oreja, se mastica o se hace presion como para tapar el oido. Es posible que el conducto del oido se ponga rojo o se hinche y que los ganglios que estan delante aumenten de tamano y duelan.  El orificio del conducto puede hacerse mas pequeno, provocando sordera temporal. A veces, sale del oido una secrecion liquida que al principio suele ser de un color claro, pero despues se torna mas espesa y amarillenta como el pus. En la mayoria de los casos el medico recetara unas gotas para los oidos que pueden contener antibioticos.
Para aliviar el dolor se pueden utilizar calmantes habituales como el ibuprofeno y el paracetamol.
No se debe meter ningun objeto en los oidos, estos se limpian solos de la cera que contienen y no es necesario hacer ninguna maniobra para extraerla.
Otitis externa, inflammation of the external ear canal, with or without middle ear involvement, is very common in dogs and quite common in cats.  Ear disease is seen in both first opinion and referral practice and, due to its frequently recurrent nature, constitutes a frustrating problem for owners and veterinarians alike. Once an otic infection has been diagnosed, medical options include topical and systemic therapy, co-adjuvated by ear cleaning, when appropriate.
Ear cleaning is an important part of any treatment regimen as it can remove debris and pus and permit complete diagnostic evaluation of the ear canal and tympanic membrane.

In the majority of cases of infectious otitis externa, topical therapy alone is sufficient. Antimicrobial agents rarely can reach, systemically, therapeutic concentrations in the skin of the ear canal and topical therapy, chosen empirically based on otic cytology and otoscopic examination, represents an appropriate choice.  Antibiotic sensitivity data reflects the serum level needed systemically, and it is less useful with topical drugs where concentrations 100 to 1000 times superior to the MIC (Minimum Inhibitory Concentration) may be reached. Topical agents, available as veterinary formulations, include marbofloxacin and orbifloxacin.
Silver Sulfadiazine (SSD) – this has broad-spectrum antibacterial activity (most notably against P.
Tromethamine–ethylenediamine-tetraacetate (TrisEDTA) –this is commonly used as either a pre-soak or a carrier vehicle in the treatment of gram negative infections.
According to manufacturer’s data, hydrocortisone aceponate (Cortavance, Virbac) has a potency similar to dexamethasone and betamethasone. The reader should remember that all the UK licensed polypharmaceutical topical ear medications are not licensed to be used in the absence of tympanic membrane, and owners should be made aware of the risks of using these medications when the tympanic membrane cannot be assessed. Considering that the middle ear (tympanic bulla) contains a highly vascular mucous membrane lining, drugs may diffuse from the vascular compartment to the bulla space better than in the external ear canals.
The administration of systemic antimicotic agents is needed in cases of otitis media caused by Malassezia spp. Ear wicks are made of polyvinyl alcohol (PVA) and are characterised by a hard compact structure.
Examples of molecules that cause ototoxicity after topical administration are aminoglycosides antibiotics, furosemide, cisplatin, vinblastin, vincristin. In pathologic condition, even the use of simple saline solution during ear flushing may cause, although infrequently, complications.
Finally, it is paramount to highlight that the majority of the studies on ototoxicity have been performed on laboratory animals or have been extrapolated by human studies. This is usually a primary infection, but can occur as the result of discharge from the middle ear. Whilst most OE is generalised less commonly a furuncle can form in association with a hair follicle. Without access to a suction device and a microscope, the use of a cotton wool ball fashioned into a spear can allow removal of a degree of discharge from the ear canal.
The important components of this therapy are the acidity and anti-inflammatory components as well their the anti-microbial activity. The use of topical steroids and resolution of the infection are critical but systemic use of NSAIDs and paractemol is also important. The fact that pseudomonas represents the commonest bacterial cause of OE does represent problems in selecting an appropriate agent, given that oral ciprofloxacin is problematic in the paediatric setting. It also allows exclusion of the presence of a foreign body (always a consideration in children). This is usually removed at 48-72 hours.Another option for difficult cases is the instillation of anti-microbial, anti-fungal and anti-inflammatory ointments to fill the canal under direct microscopic guidance. When retained water is suspected, the intermittent use of a alcohol based drop such as Swimmers ear drops is useful. Atopic dermatitis, contact dermatitis (including that to components of topical therapy) , psoriasis amongst others should always be considered. This medical information is provided to enhance and support, not replace, individual advice from a qualified medical practitioner. Eczema with secondary infection, painful fissuring of the skin at the opening of the ear canal.
In otitis media, discharge from the middle ear, coming through a perforated eardrum, causes inflammation of the ear canal skin. This is one of the reasons why it is important to clean the ear canal thoroughly, usually by microsuction.
Gradually, over a few weeks, it will work its way further out, until it passes the edge of the eardrum and passes into the ear canal skin. Humid air and lack of ventilation encouraged this mixed fungal growth on the damp surface of the fabric. Painful skin blisters in the left ear due to herpes zoster virus associated with facial paralysis.
Ear infections following swimming, dunking the head in the bath, or ear syringing, are common in otitis externa. It is a vicious circle of infection, inflammation, swelling, shedding of dead skin, more infection, and so on. Illumination is from light shone over the child’s shoulder and focussed onto the ear by a head mirror worn by the surgeon. This is normally applied under high powered microscopic control, following the removal of as much debris as possible.
Bone conduction of sound is often better than air conduction if the ear canal is blocked in otitis externa. Old fashioned bone conductor hearing aids are placed on metal springs like an Alice band, or sometimes built into a pair of spectacles. Many different factors can cause or exacerbate otitis and recognition and correction of these is the key to successful management. 2008) the antimicrobial efficacy of different ear cleaners against Staphylococcus intermedius, Pseudomonas aeruginosa and Malassezia pachydermatis was evaluated. It should always be performed under general anaesthesia with an endotracheal tube placed and cuffed, to avoid the fluids running from the ear to the respiratory tract through the Eustachian tube.
It should be performed under general anaesthesia and under direct visualisation after lavage of the external ear, when the canal is dry. Topical therapy usually is characterised by high efficacy and, with regards to the antimicrobial agents, by no systemic side effects in the presence of an intact tympanic membrane.
EDTA promotes increased permeability to extracellular solutes and increased sensitisation to antibiotics, whereas Tris serves as a buffer. 2010) reported the results of a veterinary clinical trial of a bacteriophage treatment of infection.
Dose and frequency of administration should be reduction until discontinuation when the medication is no longer needed. Usually ototoxicity can be divided: cochlear damage with consequent deafness or vestibular damage with consequent vestibular syndrome. Aminoglycosides can cause cochlear damage, with the exclusion of gentamicin that in a study(Strain et al. For this reason it is always important to inform owners about potential risks of ear flushing and topical therapy. Despite these studies representing guidelines for the clinician, further studies on other species are needed.
Evaluation of an ear cleanser for the treatment of infectious otitis externa in dogs.Vet Ther.
Diagnosis and treatment of otitis media in dogs and cats.Vet Clin North Am Small AnimPract. Comparison of pulse administration versus once daily administration of itraconazole for the treatment of Malasseziapachydermatis dermatitis and otitis in dogs. If you are confident that the tympanic membrane is intact, sofradex is the first line therapy.
Topical steroids are often indicated and the use of hypoallergenic skin and hair products recommended.
This speeds up skin metabolism and produces more layers of dead skin, which is food for the germs.
In this case, small round beige drumsticks are typical of the aspergillus (asp-er-Jill-us) flavus fungus.
There are also partially digested skin and inflammatory cells from the body, and toxic chemical waste released from both the bacteria and the body’s own defences. So, the microbiology lab report, which invariably takes time, needs to be taken with a very large pinch of salt.
Antibiotics taken by mouth don’t penetrate at all well into the layers of dead skin debris and pus that block the ear canal in otitis externa.
The view is nothing like as good, and we can’t normally reach right down to the eardrum, but it is less scary for the child. Tri-Adcortyl ® ointment contains antifungal, antibacterial and a steroid in order to reduce the inflammatory response of the skin. The test doesn’t diagnose the condition, but does tell us how much hearing has been lost.
Once the infection clears up, they go back to wearing the hearing aid, then the whole miserable cycle repeats itself. Modern digital hearing aids can be programmed to stop feedback, allowing a more open fitting.
They are cumbersome, and very uncomfortable to wear for any length of time, because they have to press very hard.

Based on history and clinical presentation, management of ear diseases include medical and surgical options. The preferred method used by the author is using a 6 French urinary catheter cut obliquely to a 60° and attached to a 2ml syringe containing sterile saline solution.
The results show that administration of this topical bacteriophage mixture leads to lysis of P. They can be systemically absorbed, with the adrenal glands function suppressed for up to 2 weeks or more after administration of some glucocorticoids for more than one week. The choice should be based on culture and susceptibility testing and, results pending, empirical treatment, based on examination of cytological specimen from the bulla content,  should be started. The expansion produces a structure that adapts to the contours of the ear canal, slowly releasing the medicaments.  In this author’s experience, ear wicks can be a useful alternative to daily topical therapy in those patients that do not tolerate administration of topical medications.
Comparison of microbial isolates and susceptibility patterns from the external ear canal of dogs with otitis externa.
Ideally therefore microscopic toilet with a suction aspirator is required, and this may be needed every couple of days. A ciprofloxacin based drop should be used when a tympanic membrane perforation is a possibility. This slow outward movement prevents a build-up of dead layers of skin from blocking the ear canal.
Most of the dust in your home is made up of those flakes of dead skin that have dropped off. The swelling of the bone is permanent, and makes it difficult to carry out microsuction treatment. The result can easily mislead doctors without specialist experience into thinking that the prescription of an antibiotic, to which the germ that happened to grow is sensitive in the lab, will cure the problem. Sometimes, and especially in younger children, it is done as a day case surgery under general anaesthetic.
It also tells us whether it is a conductive hearing loss (usually due to blockage of the ear canal in otitis externa) or a sensorineural hearing loss due to damage to the inner ear.
However, even partial blockage of the ear canal reduces ventilation and encourages infection. The aim of these notes is to describe the medical interventions available for otitis externa and media, discussing the principles of ear cleaning, ear flushing, and use of topical and systemic medications, mentioning the issues related to ototoxicity. Manual cleansing can be done at home by the owners; however it is important to instruct them on how to perform the cleaning and how often to use the different preparations. Ear flushing is best to be performed by using a video-otoscope or, if not available, with a urinary catheter or a feeding tube connected to a syringe and fluids (sterile saline), preferably through a three-way tap. The catheter is advanced through the ventral and posterior quadrant of the membrane with subsequent aspiration of the fluids.
It is paramount that the ear canals and (in the presence of otitis media) the tympanic bullae are aseptically cleaned prior to the placement, as if the canal is not adequately flushed, the wick can act as a lid trapping infections. The ototoxic agent can reach the inner ear via haematogenous route or directly through openings in the tympanic membrane. With regards to chlorhexidine, recent studies have demonstrated that if used at a 0.2% or inferior concentration, it doesn’t carry a risk of ototoxicity.
Agents with recognised ototoxic potential are polimixin B in the guinea pig and ticarcillin in the chinchilla.
On the hand, as with most of the body, skin squames get rubbed off during normal everyday activities. We need to measure and know how much hearing has been lost, and how much remains, to help advise on the likely outcome of treatment.
Although these are normally not recommended to be used more than every 48h, in one study(Cole et al.
Before ear flushing is performed, some cases may require the use of an ear cleansing solution to emulsify and remove debris. It is available as a cream and, although not readily miscible in water, a homogeneous emulsion can be achieved with gentle mixing. Additionally, in dogs with large ear canals, they often do not expand sufficiently to fill the ear canal in its entire diameter. Like dead dried leaves on a tree in autumn, the tiny flakes of dead skin are now ready to fall off. Although you can catch germs from dirty water, often it is your own resident germs who cause the trouble. Until the eardrum has been fully examined, it is impossible to know whether or not there is an underlying middle ear disease such as cholesteatoma.
The most effective way of getting around this problem is to put sound directly into the bone of the skull, by the titanium screw of a BAHA osseointegrated auditory implant.
If the ear drum cannot be visualised, care should be taken as ear cleaners are not licensed for applications in the middle ear and are all potentially ototoxic. Manual cleansing doesn’t remove tightly adherent debris or material present in the deep portion of the ear canal and therefore is best used as routine cleansing at home once ear flushing has been performed. Hearing tests before and after treatment are important in assessing the results of what we do. Otitis externa means that the inflammation is confined to the ear canal and does not go further than the eardrum.
Sometimes the wick will fall out by itself, but usually it is removed by the specialist under the microscope.
It can be quite painful to put in a wick when the ear canal is very tender and swollen, but the pain lasts only a few seconds and the relief is worth it. The inflammation and infection cause more itch, you then scratch more, which then can makes things worse. This can be due to some thick, dry skin building up in your ear canal which then narrows it. Causes of chronic otitis externa include: Sensitive ears If you get water, shampoo, soap, hairspray, etc, in your ears it may cause irritation or itch.
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. Sometimes middle ear infections (otitis media) can produce some discharge for some time which can then cause otitis externa.
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. Some swimmers use silicone rubber earplugs, but only use them if they do not irritate the skin in your ear canal. 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. These usually contain an antibiotic to clear any infection and a steroid to reduce the inflammation and itch.
If one does not work well then a doctor or nurse may advise changing to another brand with different ingredients. 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.
This may help to identify which germ is causing the infection, and which antibiotic is best to use against this germ. 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. You may need a regular clear-out of discharge every few days or so until the otitis externa has gone. Fungal 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. 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. It is less likely to recur if you follow the advice given above in the section 'sensitive ears'.
The most important thing is to avoid scratching or poking the ear canal with fingers, towels, cotton wool buds or anything else.

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