External & Middle Ear Disorders
Tug-test pain, painless foul drainage, and the ear infections that turn dangerous
Acute otitis externa
Presentation. Swimmer's ear is a cellulitis of the external canal skin. Otalgia, itch, fullness, and discharge come with pain on tragal pressure or pinna traction, the sign that separates it from acute otitis media, and the canal is red, edematous, and full of debris. Pseudomonas aeruginosa and Staphylococcus aureus are the usual organisms; moisture from swimming and trauma from cotton swabs, earbuds, or hearing aids strip the protective, acidic cerumen layer.
Treatment. After the canal is cleaned, topical drops are given for 7–10 days: a fluoroquinolone (ofloxacin, ciprofloxacin) with or without a steroid, or acidifying drops for mild disease. When edema blocks entry, an expandable wick carries drops inward. The ear is kept dry, and oral antibiotics are reserved for spread beyond the canal or an immunocompromised host. Otomycosis, with itch and black-dotted (Aspergillus) or white (Candida) debris, often follows prolonged antibiotic drops and needs cleaning plus a topical antifungal such as clotrimazole.
If the eardrum may be perforated or a tympanostomy tube is present, use only non-ototoxic fluoroquinolone drops; aminoglycosides (neomycin, gentamicin, tobramycin) and alcohol-containing or acidic drops can injure the inner ear. Neomycin is also a frequent cause of allergic contact dermatitis.
Necrotizing otitis externa
Who and why. In elderly diabetics and immunocompromised patients, Pseudomonas invades from the canal into the temporal bone and skull base, causing osteomyelitis. Pain is severe, often worse at night, and out of proportion to the findings; otorrhea is purulent; and granulation tissue sits on the canal floor at the bone–cartilage junction. The facial nerve, exiting at the stylomastoid foramen, is usually the first cranial nerve lost, followed by CN IX–XII as disease reaches the jugular foramen and hypoglossal canal.
| Feature | Acute otitis externa | Necrotizing otitis externa |
|---|---|---|
| Host | Healthy swimmer or swab user | Elderly diabetic, immunocompromised |
| Canal | Edema and debris | Granulation tissue on the canal floor |
| Nerves | Intact | CN VII first, then CN IX–XII |
| Tests | None needed | ESR/CRP, CT and MRI, biopsy and culture |
| Treatment | Topical drops 7–10 days | Antipseudomonal therapy for 6–8 weeks |
Workup and treatment. ESR and CRP are elevated and are trended to judge response. CT of the temporal bone shows bony erosion, and MRI maps soft-tissue and marrow spread. Granulation tissue is biopsied to exclude carcinoma and to culture the organism. Treatment is 6–8 weeks of antipseudomonal therapy (IV cefepime, ceftazidime, or piperacillin-tazobactam, or high-dose ciprofloxacin), tight glucose control, and debridement for refractory disease.
Complications of otitis media
Acute mastoiditis. Spread of AOM into the mastoid air cells causes fever, postauricular redness, swelling, and tenderness, loss of the postauricular crease, and an auricle pushed forward and outward. Streptococcus pneumoniae is the most common cause. Management is admission, contrast CT of the temporal bone to look for abscess or intracranial extension, IV antibiotics (e.g., ceftriaxone), and myringotomy with or without a tube for drainage and culture; mastoidectomy is reserved for subperiosteal abscess or failure to improve.
| Complication | Clue |
|---|---|
| Bezold abscess | Neck swelling deep to the sternocleidomastoid |
| Petrous apicitis | Gradenigo syndrome: otorrhea, retro-orbital (CN V) pain, CN VI palsy |
| Facial nerve palsy, labyrinthitis | Facial weakness; vertigo with sensorineural loss |
| Meningitis, epidural or brain abscess | Headache, fever, lethargy, focal signs |
| Sigmoid sinus thrombosis | Headache, papilledema; confirm with venography |
Tympanic membrane perforation. AOM can rupture the drum (pain eases as pus drains), as can cotton swabs, slaps, blasts, and barotrauma, producing conductive loss and bloody or purulent otorrhea. Most small perforations heal within weeks if water is kept out; ototoxic drops are avoided, and a fluoroquinolone is used if the ear is infected. A perforation unhealed after about 2–3 months, or chronic drainage through it, is referred for tympanoplasty.
Vertigo, nystagmus, sensorineural loss, or facial weakness after ear trauma suggests inner-ear or ossicular injury such as a perilymph fistula and needs urgent ENT evaluation.
Cholesteatoma and otitis media with effusion
Cholesteatoma. This is keratinizing squamous epithelium trapped in the middle ear and mastoid. The acquired form grows from a chronic retraction pocket in the pars flaccida (attic) caused by eustachian tube dysfunction; the congenital form is a white pearl behind an intact eardrum in a child without otitis. Typical findings are painless, foul, persistent otorrhea despite drops, conductive hearing loss, and white keratin debris in the pocket. Expanding keratin and its enzymes erode the ossicles, lateral semicircular canal (fistula, vertigo), facial canal (CN VII palsy), and tegmen (meningitis, brain abscess). CT of the temporal bone and audiometry precede surgical excision (tympanomastoidectomy); antibiotics only quiet the infection.
Otitis media with effusion. Middle-ear fluid without acute inflammation shows a dull or retracted drum, air-fluid levels or bubbles, and poor mobility on pneumatic otoscopy or a flat tympanogram. It often follows AOM and usually clears within 3 months, so management is watchful waiting; antibiotics, steroids, antihistamines, and decongestants do not help.
- Diagnosepneumatic otoscopy, tympanometry
- Watch for 3 monthsre-examine; no medications
- Test hearingif the effusion persists 3 months or longer
- Tympanostomy tubesbilateral OME ≥3 months with hearing loss, or persistent OME in at-risk children (speech or developmental delay)
Tube otorrhea is treated with topical fluoroquinolone drops, not oral antibiotics. A new unilateral effusion in an adult warrants a look at the nasopharynx for carcinoma.
Canal obstruction, auricular trauma, and Ramsay Hunt syndrome
Cerumen impaction. Wax is removed only if it causes symptoms (hearing loss, fullness, tinnitus, cough) or blocks a needed exam. Options are cerumenolytic drops (carbamide peroxide, docusate, saline), warm-water irrigation, or manual removal with curette or suction. Irrigation is avoided with a possible perforation, a tube, or prior ear surgery, and used cautiously in diabetic or immunocompromised patients because of necrotizing otitis externa risk. Cotton swabs and ear candling are discouraged.
Foreign bodies. A button battery causes liquefactive necrosis of the canal, eardrum, and ossicles within hours and must be removed emergently, never irrigated. A live insect is first immobilized with mineral oil or lidocaine, then removed. Organic matter that swells, such as beans, should not be irrigated, and round or deeply lodged objects are removed by ENT under the microscope.
Auricular hematoma. Blunt shear in wrestling, boxing, or rugby lifts the perichondrium off the cartilage, which depends on it for blood supply. Without prompt aspiration or incision and drainage plus a compressive bolster, the cartilage necroses and fibroses into a cauliflower ear; the patient is rechecked within days for reaccumulation. Perichondritis after high cartilage piercing is usually Pseudomonas, spares the lobule, and is treated with a fluoroquinolone.
Ramsay Hunt syndrome. Reactivation of varicella-zoster virus in the geniculate ganglion produces painful vesicles in the canal and concha with an ipsilateral lower motor neuron facial palsy involving the forehead, sometimes with hearing loss, tinnitus, and vertigo from CN VIII involvement. Valacyclovir or acyclovir plus prednisone should start early, and the eye that cannot close needs lubrication by day and ointment with taping at night. Recovery is less complete than in Bell palsy.