Ear canal inflammation – Swimmer’s Ear (Otitis Externa): Causes, Diagnosis, Treatment

An ear canal is an inflammation of the skin of the ear canal. This is also called a “swimmers’ ear” or otitis externa. Ear canal inflammation is one of the most frequently diagnosed in ENT practice. Approximately three to ten percent of ENT patients visit the ENT doctor with complaints of ear canal infections. Often one patient has an ear canal several times a year. The inflammation is usually caused by a bacterium, but a fungal infection is also possible.

Ear canal

The ear consists of the outer ear, the middle ear and the inner ear. The outer ear and ear canal form the outer ear. Outer ear and middle ear are separated by the eardrum.

The external ear canal runs from the earcup to the eardrum and directs the sound to the eardrum. The external ear canal is a slightly curved canal covered with skin. In adults, the ear canal is approximately 2.5 cm long and approximately 1 cm in diameter.

There are 1,000 to 2,000 glands in the skin of the ear canal that produce ear wax. This ensures that the acidity in the ear remains good and thus takes care of the skin in the ear canal.

Earwax serves, among other things, to protect the ear against dirt, dust, bacteria, etc. and transports dander and dirt from the ear canal to the outside. The amount of ear wax can vary per person and even per ear.

Origin of an ear canal infection

The skin of the ear canal is protected by the ear wax, which is acidic and greasy. If the protective factors, such as earwax and intact epidermis, fall away, there is an increased risk of an ear canal.

The best known causes of an ear canal are:

Swimming and bathing

The humidity level in the ear canal is hereby increased and it becomes less acidic, which increases the chance of inflammation. That is why an ear canal infection is also called “swimmers’ ear”.

Ear pruning

When picking in the ear canal and cleaning it yourself with cotton buds, pens, paper clips, matches, keys etc. wounds can occur. This also allows the earwax to be pushed deeper into the ear canal. A plug of ear wax can then also form. Inflammation is easier in the sultry space behind this plug.

Disturbed aeration

A reduced aeration of the ear canal can already give rise to inflammation, for example by prolonged closure of the ear canal with an ear plug. People with a narrow ear canal are more likely to suffer from ear canal infections.

Hair growth

The more hairs are in the outer part of the ear canal, the greater the chance of inflammation due to a disruption of the normal earwax transport mechanism.

Cosmetic products

For example, shampoo, soap and hair spray can irritate the skin in the ear canal. If the skin becomes irritated, it is vulnerable and inflammation can occur more easily.

Allergic skin reaction

Allergic reactions to headphones, (ear pieces of) hearing aids and ear drops can lead to scratching of the ears, resulting in minor damage to the ear canal with increased risk ofinflammation.

Relationship between ear canal inflammation and other disorders

The ear canal may be part of a skin disease such as eczema, psoriasis or contact allergy. With these disorders itchiness is the main thing. During the examination, a (ENT) doctor will therefore also pay attention to the hairy scalp and, for example, the elbow.

Diabetes must also be asked when going through the history of illness. Blood vessel damage based on diabetes can lead to locally reduced blood flow, which can result in skin and cartilage degradation. This same blood vessel damage also makes antibiotic treatment and the body’s immune response less efficient to be.

Causes of an ear canal

Bacterium

The ear canal is usually caused by bacteria in combination with damaged skin. This concerns in a majority of cases the bacterium Pseudomonas aeruginosa. Pseudomonas aeruginosa can seldom or never come from a healthy ear canal. This is in contrast to an ear canal with damaged skin.

In half the number of cases the inflammation is caused by several bacteria at the same time.

Mold

A fungus as the cause must also be considered. A fungus occurs mainly in a humid, warm climate. That is why a fungal infection of the ear canal is observed more frequently in the summer in the Netherlands. It is then warm and more is being swum, leaving water in the ear canal coming.

Complaints of the different types of ear canal infections

Acute ear canal inflammation

In the acute form the patient will often complain about itching and pain. The pain can be so severe that it prevents the patient from sleeping. There are also often complaints of feeling full in the ear and hearing loss.
Upon examination of the earcup and entrance of the ear canal one sees:

• a red, swollen skin of the ear canal; sometimes up to the pinna with narrowing of the ear canal and / or
• a barrel ear and crusting.

Pressure on the cartilage before the ear is painful. The insertion of an ear view by the (ENT) doctor and pulling the ear back is painful. An extensive form of ear canal inflammation will also cause fever and swelling of the lymph nodes around the ear and neck. Due to the swelling or discharge, a patient may temporarily have difficulty hearing.

Chronic ear canal inflammation

With chronic ear canal inflammation, the pain is less prominent. It is mainly the relentless itching that hinders. The skin can be dry and flaky, but also moist (oar). In the case of chronic inflammation, taking a culture can be important to detect the causative agent of the inflammation. Sometimes it is necessary not to use antibiotic-containing ear drops for some time prior to ear culture.

Fungal infection of the ear canal

In the case of a fungal infection, a thick discharge is found in the ear canal (image of “wet newspapers”). The (ENT) doctor can often recognize the fungal infection when inspecting the ear through black dots or white “cotton wool” amid the outflow. A blue-green or yellow discoloration can also be seen depending on the fungal species.

Prolonged use of certain ear drops encourages the development of a fungal infection by altering the normal balanced composition of the bacteria in the ear canal. It creates space for molds, as it were. An ear culture can suspect a fungal infection confirm.

Investigation in an ear canal

The diagnosis of ear canal inflammation is almost always based on the pattern of complaints and the examination of the ear. In some cases, additional examinations will be required in the form of taking a culture, taking X-rays or conducting tissue tests.

If a contact allergy is suspected, additional allergy testing by a dermatologist may be required to be.

Treatment of an ear canal

In almost all cases, ear canal inflammation is limited to the skin of the ear canal and can easily be cured with local (local) treatment. The complaints disappear after one to two weeks.

Different treatments are possible depending on the type of inflammation:

Acute ear canal inflammation

In the acute form of ear canal inflammation, it is important to thoroughly clean the ear canal (by the (knot) doctor) without damaging the skin (so-called “ear toilet”). As long as this is not done, any treatment will be less effective. The best way to do this is under the sight of an ear microscope by suctioning with a small vacuum cleaner. If the crusts cannot be removed properly, it may be necessary to first drip.

Since the ear canal with the acute inflammation is sometimes narrowed, dripping afterwards – by the patient himself – will not be sufficient. After all, the ear drop does not reach the location of the inflammation sufficiently. For this reason, after cleaning, a tampon (gauze strip) is often inserted deep into the ear canal with an acid ear drop or an anti-inflammatory and antibiotic.

It may be necessary to clean the ear canal several times a week and re-insert a clean tampon. If the ear canal has become sufficiently spacious, you can proceed to drip without tampon.

The administration of acid ear drops can cause a burning sensation. Ear drops are often prescribed that contain a corticosteroid, whether or not in combination with one or more types of antibiotics.

Chronic and dry ear canal inflammation

In the chronic form of ear canal inflammation based on eczema and in the dry form of ear canal inflammation, a corticosteroid-containing ear drop often helps enough. The treatment approach is otherwise the same as in the acute form: ear toilet and the use of ear drops, the choice of which is partly determined by the outcome of the culture test.

Fungal infection ear canal

A fungal infection is treated by means of a thorough ear toilet followed by the use of acid ear drops or an antifungal medicine, which can be administered locally via an ear drop or via a tablet or drink. A corticosteroid-containing ear drop should be avoided. In persistent cases, an anti-fungal cream is applied to a tampon.

Pain relief

If the pain is in the foreground, pain relief will be added to the local treatment. In most cases, drugs with analgesic and antipyretic effects are sufficient, which also have an anti-inflammatory effect (so-called NSAIDs).

Antibiotic

Rarely is an antibiotic cure required. If, in the opinion of the (ENT) doctor, this is necessary, it will preferably be given after taking a culture. If the crop is not cultivated – or an antibiotic is already started before the results of the culture is known – a broad-acting antibiotic is preferable due to the fact that the inflammation is often caused by several bacteria at the same time.

Operation

Rarely is surgery required for ear canal inflammation. The cause of a recurring or poorly curable ear canal inflammation can be a narrow entrance to the ear canal. In that case an ear canal operation (meatus plastic) can be chosen, whereby cartilage is removed from the outer part of the ear canal. This procedure can be performed under local anesthesia. In some cases, the bony part of the ear canal also needs to be widened. Usually it is general anesthesianecessary.

Special forms of ear canal inflammation

Boil

A boil can also develop in the ear canal. The boil is caused by the occlusion of a sebaceous gland in the outer third of the ear canal. This causes a local thickening in the ear canal, accompanied by severe pain and sometimes with fever.

The boil causes extreme pain until it is opened (drainage). This drainage can occur spontaneously, but often help is sought sooner and the boil will have to be relieved. In many cases, ear drops and an antibiotic cure will also be given to become.

Necrotizing otitis externa (malignant otitis externa)

In patients with greatly reduced resistance and / or diabetes patients, ear canal inflammation can spread in the surrounding bone tissue. This is then referred to as a necrotizing external otitis. Severe earache, fever and being sick occur.

A necrotizing otitis externa requires treatment with frequent ear toilets, tamponing, antibiotics and possibly optimal regulation of (possible) diabetes. This is a specialized treatment that usually has to take place in the hospital with an intravenous antibiotic and one ear surgery.

Ear drops

The ear drops for an ear canal are often the same as the ear drops that are given for a carpal caused by a middle ear infection and a hole in the eardrum. Many objections described on the information page about  ear drops  do not apply here, as long as the eardrum is intact.

When using ear drops, a patient should realize that a contact allergy may occur or already exists. The complaints here are the same as those due to external otitis. Because of this it may happen that people think that they treat otitis externa, while the disease is maintained precisely by these drops.

For the commonly used substance neomycin, about 2% of the population has a contact allergy. If this medicine is used more often, such as in the “swimmers’ ear”, this percentage rises to 15%!

For yet another component of a certain ear drop (propylene glycol), the percentage even rises to 50% after frequent use. This substance is also found in many so-called ear wax dissolvers, which are advertised as “cleaner” of the ear canal. Be very cautious about using these resources.

If the ear canal inflammation does not respond well to treatment with ear drops within one week, there may be an allergic reaction to the ear drops or earwax remover. Then contact your ENT doctor. You must also contact us if you develop a fever or if you become ill feels.

Prevention and advice

In addition to the treatments described above, the prevention of inflammation is of great importance. For optimum prevention of ear canal inflammation, also read the information leaflet about  earwax .

The recommendations are summarized here:

• the ear canal generally cleans itself;
• avoids fiddling in the ears;
• only remove visible earwax;
• do not use matches or hairpins to clean the ear canal;
• after swimming or showering, drain the water from the ear canal by tilting the head and shaking;
• careful drying out with a tissue or hair dryer (see  earwax ) is also allowed;
• if the inflammation always develops after swimming, you can now use a cotton ball with Vaseline, a swimming cap or ear plugs to protect the ear canal;
• avoid (cosmetics) products if you notice that they irritate the skin;
• If you often have ear canal complaints when using a hearing aid , have the hearing care professional check if the earpiece fits properly and make an appointment with your ENT specialist to assess your ear.

Final word

It is not possible to describe all details of an ear canal infection on this information page.
It may be that despite the explanation of your ENT specialist you still have questions or you want more information. Do not hesitate to contact your ENT doctor and ask for further explanation.
That request will gladly be met.