Outer Ear Infections and the Role of Ear Microsuction
What is otitis externa (Outer Ear Infection)?
Otitis externa (also called Swimmer’s Ear or Outer Ear Infection) is a condition where the canal and outer part of the ear becomes inflamed and painful. It is usually caused by either bacterial or fungal infections. About 1 in 10 people will experience otitis externa during their lifetime.
Bacterial infections are more common, especially those caused by pseudomonas or staphylococcus aureus. Fungal infections are rarer, but can be more serious. Aspergillosis is the most common type of fungal infection, and candida is the second most common. Occaisonally both bacteria and fungi are present.
Bacteria and fungi love warm, humid environments, so things like living in a hot climate, swimming or surfing can increase your risk. Certain inflammatory conditions such as psoriasis and dermatitis can also increase your risk, as the skin around your ear becomes more fragile and no longer provides a protective barrier. Injury to your ear canal can also predispose you to otitis externa, which is why you should never stick anything inside your ear.
With correct treatment most cases of acute otitis externa will improve within the first 3 days.
How is otitis externa diagnosed?
Otitis externa is generally a clinical diagnosis, meaning your doctor will diagnose it based on a set of signs and symptoms. You will be asked about pain, discharge, hearing loss and feelings of fullness or itchiness.
Your doctor will perform an examination of your ear, looking for swelling of the canal, redness and discharge. In fungal infections spores can often be seen in your ear canal. The appearance is often described as looking like cotton wool or wet newspaper. Bacterial infections are less specific, but there may be discharge in the canal.
Your doctor will also check your temperature and look for any enlarged lymph nodes which could indicate a more serious infection.
If you have further risk factors such as diabetes, recurrent infections or take medications which can impair your immune function, they may also take swabs from your ear to confirm the type of organism that is causing the infection. The results of these swabs generally take a few days to come back. However, they are useful if your condition doesn’t start to improve with the initial antibiotics drops you are prescribed.
How is otitis externa treated?
Otitis externa is treated with a combination of ear drops, ear cleaning and pain relief.
What types of ear drops are used to treat acute otitis externa?
2 main types of antibiotic drops are used to treat otitis externa caused by bacteria. If there is a perforation of your ear drum, or it cannot be completely inspected due to swelling or debris, a quinolone-based drop will be used. These can be more expensive, but are much safer if the ear drum is perforated.
Non-quinolone based antibiotic drops are usually cheaper, but they can cause damage to the fragile cells in your middle ear. Therefore, they should only be used if the ear drum is completely intact.
Ear drops may also contain topical steroids which can help to reduce the inflammation in your ear canal. Because the steroids and antibiotics are administered locally, they are less likely to cause side effects compared to oral formulations which act systemically (on the whole body).
The most common ear drops used to treat bacterial otitis externa in Australia include;
Quinolone based
Ciprofloxacin (Ciloxin)
Ciprofloxacin + steroid (Ciproxin HC)
Non-Quinolone based
Framycetin (Soframycin)
Framycetin + gramicidin + steroid (Sofradex)
If a fungal infection is suspected, the one of the following types of ear drops will be used;
Neomycin + gramicidin + triamcinolone (Kenacomb Otic or Otocomb Otic)
Clioquinol + flumetasone (Locacorten-Vioform)
Clotrimazole (Canesten)
Oral antibiotics are not recommended for the treatment of simple, uncomplicated otitis externa. However, they may be used if you also have a fever, cellulitis or enlarged lymph nodes in the surrounding area.
What should I take for pain relief?
Otitis externa can be painful. Over the counter medications such as paracetamol and anti-inflammatories (if it is safe for you to take them) are effective, and it is best to take these regularly, rather than waiting until the pain builds up.
How can ear microsuction help treat otitis externa?
Microsuction is the preferred method of clearing the ear in otitis externa. You might need to undergo microsuction several times to help clear discharge and debris so the antibiotics can reach all the affected areas. If your ear canal is very swollen a wick may also be inserted to allow the antibiotics to penetrate the canal better.
Microsuction is the safest and most comfortable method of removing debris from the ear canal. As it doesn’t introduce any fluids into your ear, it is less likely to cause pain compared with syringing, especially if your ear is swollen and inflamed.
It is also much safer if your ear drum can’t be seen due to debris, as syringing is contraindicated in people with a perforated ear drum.
Syringing can also increase your risk of developing complications such as necrotising otitis externa, a severe form of infection, which can spread to the surrounding bone.
What can I do to reduce my risk of getting otitis externa again?
There are several things you can do to reduce your risk of developing otitis externa again.
Firstly, never stick anything inside your ear canal. Trauma from sticking things like cotton buds or paper clips into the ear canal allows bacteria to break through the protective barrier provided by the skin.
Secondly, keep your ears as dry as possible. Water exposure can increase your risk of developing otitis externa. Water accumulation decreases the acidity in the ear canal and makes it easier for bacteria and fungi to grow. Ear plugs can be useful when swimming or engaging in other aquatic activities. Shower caps can prevent irritating chemicals from shampoos and soap getting into the ear canal.
It is also best to avoid syringing, which introduces water into your ear canal and can create the moist, humid environment that bacteria and fungi thrive in.
Finally, acetic acid ear drops (Aqua Ear) can be used after showering or swimming to help prevent further episodes. These should only be used if you have an intact eardrum.
Further Reading
Lee J, Yau S. Approach to otitis externa in Australian general practice. Australian Journal of General Practice. 2024 Dec;53(12):935-41. https://www1.racgp.org.au/ajgp/2024/december/approach-to-otitis-externa-in-australian-general-p
Mather MW, Mohammed H, Wilson JA. Improving patient care pathways in otitis externa. Family Practice. 2022 Oct 1;39(5):971-3. https://academic.oup.com/fampra/article/39/5/971/6505226
Perth Children’s Hospital. Otitis Externa. Emergency Department Guidelines. Jan 26. https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Otitis-externa
