Otitis externa

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.

Read more about the symptoms of otitis externa

When to see your GP

You should see your GP if you may have otitis externa.

Your GP will ask 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 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
• allergies

There are a number of things that can make you more likely to develop otitis externa, including:

• damaging the skin inside your ear
• 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.

Read more about the causes of otitis externa.

Who is affected?

Otitis externa is relatively common. It's 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 45 to 75 years of age.

People with certain long-term (chronic) conditions are at greater risk of developing the condition. These include:

• eczema
• asthma
• allergic rhinitis

How otitis externa is treated

Otitis externa sometimes gets better without treatment, but it can take several weeks. Your GP can prescribe ear drop medication that usually improves 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.

Read more about treating otitis externa

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're 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.

Read more about preventing otitis externa

Complications

Complications of otitis externa are uncommon, but some can be very serious.

One rare complication of otitis externa is necrotising 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.

Read more about the complications of otitis externa

Otitis externa can cause a number of different symptoms affecting the ear and the surrounding area.

Symptoms can include:

• ear pain
• 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 happens, you may be able to see the pimple or boil in a mirror. However, don't attempt to squeeze any pimples or boils in your ear, as this could lead to the infection spreading elsewhere.

Long-term symptoms

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

There are several different causes of otitis externa. A number of things can also increase your chance of developing the condition.

Common causes

Causes of otitis externa can include:

• a bacterial infection – usually by bacteria called Pseudomonas aeruginosa or Staphylococcus aureus
• seborrheic dermatitis – a common skin condition where the naturally greasy areas of your skin 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 don't complete the full course of recommended treatment.

Possible triggers

The following things aren't direct causes of otitis externa, but may make the condition more likely to develop.

Excessive moisture

Liquid in your ear canal can make you more likely to develop an infection. Moisture provides an ideal environment for bacteria – and to a lesser degree, fungi – to grow.

Your risk may be increased by:

• swimming – particularly in dirty or polluted water
• sweating
• being exposed to humid environments

Water can also wash away earwax inside your ears, which can make them itchy.

Ear damage

Your ear canal is very sensitive and may become damaged through:

• scratching inside your ears
• excessive cleaning
• inserting cotton buds
• wearing ear plugs or in-ear headphones for long periods

Using a hearing aid may also increase your risk of developing otitis externa.

Chemicals

Your chances of getting otitis externa are increased if you use certain products in or near your ears, such as:

• hair sprays
• hair dyes
• earwax softeners

Underlying skin conditions

As well as seborrheic dermatitis, certain underlying skin conditions can increase your risk of otitis externa. These include: 

• psoriasis
• eczema
• acne

Allergic conditions

If you have allergic rhinitis or asthma, you may be at a higher risk of developing otitis externa.

Weak immune system

You may be at higher risk of developing otitis externa if you have a condition that can weaken your immune system, such as:

• diabetes
• HIV or AIDS

Certain cancer treatments, such as chemotherapy, may also increase your risk of 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 to relieve your symptoms to some extent and help to 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 to 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're 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 the ear drops don't come out of your ear canal
• leave the ear canal open to dry

Other treatments

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 seborrheic 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 shouldn't attempt to do it yourself

Specialist treatment

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
• micro suction – 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.

Although complications associated with otitis externa are uncommon, there's a small risk of further problems developing.

Some of the main complications of otitis externa are described below.

Abscesses

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, in rare cases, can even cause deafness. However, it can usually be treated with ear drops.

Inflamed or perforated eardrum

It's 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.

Symptoms include:

• 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 heals without treatment in a couple of months. Surgery may be recommended if it shows no signs of healing after this time.

Cellulitis

Cellulitis is a bacterial skin infection that can occur after otitis externa. It's what happens 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:

• feeling sick
• shivering
• chills
• a general sense of feeling unwell

Most cases of cellulitis can be treated with a seven-day course of antibiotics.

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.

Necrotizing otitis externa

Nectrotizing 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
• with certain long-term health conditions, such as diabetes or HIV

Signs and symptoms of necrotizing 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, necrotizing otitis externa can be fatal. However, it can be effectively treated using antibiotics and surgery to remove any damaged tissue.

It's not always possible to prevent otitis externa, but you can reduce your risk of developing the condition.

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).
• Don't swim in polluted water.
• Turn your head from side to side after getting out of water. This helps water drain from your ears.
• Don't stick anything into your ear canal. This includes pens/pencils, fingers, bobby clips or cotton-tipped swabs. Swabs should only be used to dry the outer ear.

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 to prevent otitis externa recurring.