Otitis externa overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Otitis externa ("swimmer's ear") is an inflammation of the outer ear and ear canal. Along with otitis media, external otitis is one of the two human conditions commonly called "earache". It also occurs in many other species. Inflammation of the skin of the ear canal is the essence of this disorder. The inflammation can be secondary to dermatitis (eczema) only, with no microbial infection, or it can be caused by active bacterial or fungal infection. In either case, but more often with infection, the ear canal skin swells and may become painful and/or tender to touch.
Chronic otitis externa is a low-grade disease, usually non-microbial and purely on the basis of chronic dermatitis or irritation from "cleaning" the canal, often with cotton swabs. It can be thought of as chronic dermatitis of the ear canal skin and may or may not be painful. There may only be seepage, mild swelling, or itching.
In contrast to the chronic otitis externa, acute otitis externa is predominantly a microbial infection, occurs rather suddenly, rapidly worsens, and becomes very painful and alarming. The ear canal has an abundant nerve supply, so the pain is often severe enough to interfere with sleep. Wax in the ear can combine with the swelling of the canal skin and any associated pus to block the canal and dampen hearing to varying degrees, creating a temporary conductive hearing loss. In more severe or untreated cases, the infection can spread to the soft tissues of the face that surround the adjacent parotid gland and the jaw joint, making chewing painful. In its mildest forms, external otitis is so common that some ear nose and throat physicians have suggested that most people will have at least a brief episode at some point in life. While a small percentage of people seem to have an innate tendency toward chronic external otitis, most people can avoid external otitis altogether once they understand the mechanisms of the disease.
The skin of the bony ear canal is unique, in that it is not movable but is closely attached to the bone, and it is almost paper thin. For these reasons it is easily abraded or torn by even minimal physical force. Inflammation of the ear canal skin typically begins with a physical insult, most often from injury caused by attempts at self-cleaning or scratching with cotton swabs, finger nails, hair pins, keys, or other small implements. Another causative factor for acute infection is prolonged water exposure in the forms of swimming or exposure to extreme humidity, which can compromise the protective barrier function of the canal skin, allowing bacteria to flourish; hence the name, "swimmer's ear". Densely impacted wax, usually caused by enthusiastic use of cotton swabs, can put enough pressure on the ear canal skin to injure it and initiate infection. A sensation of blockage or itching can prompt attempts to clean, scratch, or open the ear canal, which potentially worsens and perpetuates the condition. The cotton fibers of a swab are abrasive to the thin, fixed canal skin. Self-manipulative measures to improve the condition often make it worse and are to be discouraged, since it is a blind exercise that can result in significant injury to the ear. Production of wax by glands in the canal may be hindered by external otitis. The exact function(s) of cerumen (earwax) is a subject that is open to speculation, since there is very little research regarding its function. Some caretakers feel strongly that earwax has a protective function with respect to infection and that a little earwax in the ear canal is a good thing.
A natural question is, "How can I clean my ears, then?" It is well established that in most people the top layer of the ear canal skin normally migrates toward the ear opening, essentially sweeping the canal on a continuing basis. In other words, a normal ear canal is self-cleaning. This self-cleaning physiologic feature fails in some patients, especially in late life, and periodic cleaning by a physician can be necessary. The most controlled and least painful means of cleaning impacted wax or dead skin from the ear canal is by using a binocular surgical microscope, which frees the examiner's hands to instrument the ear and provides the magnification and depth perception needed to avoid traumatizing the delicate canal skin and eardrum.
There is an uncommon and serious form of external otitis called malignant or necrotizing external otitis, in which the infection extends beyond the confines of the ear canal and can involve the bone of the skull. Although the name of this condition contains the words "external otitis" it tends to follow a more severe and chronic clinical course and can lead to skull base osteomyelitis. Instead of being a condition that most people are subject to, necrotizing external otitis (also called malignant otitis externa) is a life-threatening disorder that only affects older individuals with diabetes and patients with major disorders of the immune system. This uncommon complication of external otitis is discussed under Complications, below.[1]
References
- ↑ Beers S, Abramo T (2004). "Otitis externa review". Pediatr Emerg Care. 20 (4): 250–6. PMID 15057182.