Outer Ear Disorders

Introduction

The outer ear consists of the external part of the ear (pinna or auricle) and the ear canal. Disorders of the outer ear include blockages, infections (external otitis and perichondritis), eczema, and tumors. The outer ear is also prone to certain types of injury.

Earwax (cerumen) may block the ear canal. Even large amounts of earwax often cause no symptoms. Symptoms can range from itching to a loss of hearing. A doctor may remove the earwax by gently flushing out the ear canal with warm water (irrigation). However, if a person has had a perforated eardrum, irrigation is not used because water can enter the middle ear and may cause a middle ear infection. Similarly, irrigation is not used if there is any discharge from the ear, because the discharge may be coming from a perforated eardrum. In these situations, a doctor may remove earwax with an earwax curette, an instrument with a loop at the end, or a vacuum device.

 

Certain solvents help soften earwax, but they usually must be followed by irrigation, because the solvent rarely dissolves all of the earwax. People should not attempt removal at home with cotton swabs, bobby pins, pencils, or any other implements. Such attempts usually just pack the earwax in more and can damage the eardrum. Soap and water on a washcloth provide adequate external ear hygiene.

 

Other blockages can occur when people, particularly children, put foreign objects, such as beads, erasers, and beans, into the ear canal. Usually, a doctor removes such objects with a blunt hook or small vacuum device. Sometimes metal and glass beads can be flushed out by irrigation, but water causes some objects, such as beans, to swell, complicating removal. Objects that are deep in the canal are more difficult to remove because of the risk of injury to the eardrum. A general anesthetic is used when a child does not cooperate or when removal is particularly difficult.

 

Insects, particularly cockroaches, may also block the ear canal. To kill the insect, a doctor fills the canal with mineral oil or thickened lidocaine, a numbing agent. This measure also provides immediate pain relief and enables the doctor to remove the insect.

External otitis is infection of the ear canal.

  • External otitis is caused by bacteria or, rarely, fungi.
  • Typical symptoms are itching, pain, and discharge.
  • A doctor looks in the ear with an otoscope (a device for viewing the canal and eardrum) for redness, swelling, and pus.
  • Drops may help prevent swimmer's ear.
  • Debris removal, ear drops, and pain relievers are the most common forms of treatment.

External otitis may affect the entire canal, as in generalized external otitis, or just one small area, as in a boil (furuncle) or pimple.

 

Causes

A variety of bacteria or, rarely, fungi can cause generalized external otitis. Certain people, including those who have allergies, psoriasis, eczema, or scalp dermatitis, are particularly prone to external otitis. Injuring the ear canal while cleaning it or getting water or irritants such as hair spray or hair dye in the canal often leads to external otitis. External otitis is particularly common after swimming, in which case it is sometimes called swimmer's ear. Earplugs and hearing aids make external otitis more likely, particularly if these devices are not properly cleaned.

 

Symptoms and Diagnosis

Symptoms of generalized external otitis are itching and pain. Sometimes an unpleasant-smelling white or yellow discharge drains from the ear. The ear canal may have no swelling or slight swelling, or, in severe cases, it may be swollen completely closed. If the ear canal swells or fills with pus and debris, hearing is impaired. Usually, the canal is tender and hurts if the external ear (pinna) is pulled or if pressure is placed on the fold of skin in front of the ear canal (tragus). To a doctor looking into the ear canal through an otoscope, the skin of the canal appears red and swollen and may be littered with pus and debris.

 

Boils cause severe pain. When they rupture, a small amount of blood and pus may leak from the ear.

 

Prevention and Treatment

Swimmer's ear may be prevented by putting drops of a solution containing half rubbing alcohol and half vinegar in the ear before and after swimming. Attempting to clean the canal with cotton swabs interrupts the normal, self-cleaning mechanism and can push debris toward the eardrum, where it accumulates. Also, these actions may cause minor damage that predisposes to external otitis.

 

To treat generalized external otitis from any cause, a doctor first removes the infected debris from the canal with suction or dry cotton wipes. After the ear canal is cleared, hearing often returns to normal. Usually, a person is given ear drops containing vinegar and drops containing a corticosteroid such as hydrocortisone to use several times a day for up to a week. Vinegar is helpful because bacteria do not grow as well once the normal acidity of the ear canal is restored. With moderate or severe infection, antibiotic drops also are prescribed. If the ear canal is very swollen, a doctor inserts a small wick in the canal to allow the drops to penetrate.

 

Analgesics or codeine may help reduce pain for the first 24 to 48 hours, until the inflammation begins to subside. An infection that has spread beyond the ear canal may be treated with an antibiotic given by mouth.

 

Treatment of boils depends on how advanced the infection is. In an early stage of infection, a heating pad can be applied for a short time and analgesics can be given to help relieve pain. The heat may also help speed healing. A boil that has come to a head is cut open to drain the pus. An antibiotic is then applied directly to the area or given by mouth.

 

Malignant External Otitis

Malignant external otitis is infection of the external ear that has spread to involve the skull bone containing part of the ear canal, the middle ear, and the inner ear (temporal bone).

 

Malignant external otitis occurs mainly in people with weakened immune systems and in older people with diabetes. Infection of the external ear, usually caused by the bacteria Pseudomonas, spreads into the temporal bone, causing severe, life-threatening infection.

 

People have severe earache, a foul-smelling discharge from the ear, and usually decreased hearing.

 

The diagnosis is based on computed tomography (CT) scan results. Often doctors need to take a small piece of tissue from the ear canal to make sure that the symptoms are not the result of cancer.

 

Malignant external otitis is treated with a 6-week course of antibiotics given by vein.

A number of different injuries can affect the outer ear. A blunt blow to the external ear can cause bruising between the cartilage and the layer of connective tissue around it (perichondrium). When blood collects in this area, the external ear becomes swollen and purple. The collected blood (hematoma) can cut off the blood supply to the cartilage, allowing that portion of the cartilage to die, leading in time to a deformed ear. This deformity, called a cauliflower ear, is common among wrestlers, boxers, and rugby players.

 

A doctor cuts open the hematoma and removes the blood with suction. After the hematoma is empty, the doctor applies a compression dressing, which is left on for 3 to 7 days to keep the hematoma from coming back. The dressing keeps the skin and perichondrium in their normal positions, allowing blood to reach the cartilage again.

 

If a cut (laceration) goes all the way through the ear, the area is cleaned thoroughly, the skin is sewn back together, and a dressing is applied to protect the area and allow the cartilage to heal. The cartilage is not sewn.

 

A forceful blow to the jaw may fracture the bones surrounding the ear canal and distort the canal's shape, often narrowing it. The shape can be corrected surgically.

Perichondritis is infection of the tissue surrounding the cartilage of the earlobe (pinna), ear canal, or both.

 

Injury, burns, insect bites, ear piercing, or a boil on the ear may cause perichondritis. The infection also tends to occur in people whose immune system is weakened and in people who have diabetes. The first symptoms are redness, pain, and swelling of the earlobe. The person may have a fever. Pus accumulates between the cartilage and the layer of connective tissue around it (perichondrium). Sometimes the pus cuts off the blood supply to the cartilage, destroying it and leading eventually to a deformed ear. Although destructive and long-lasting, perichondritis tends to cause only mild discomfort.

 

A doctor makes an incision to drain the pus, allowing blood to reach the cartilage again. Antibiotics are given by mouth for milder infections and by vein for severe infections. The choice of antibiotic depends on how severe the infection is and which bacteria are causing it.

Tumors of the ear may be noncancerous (benign) or cancerous (malignant). Most ear tumors are found when people see them or when a doctor looks in the ear because people notice their hearing seems decreased.

 

Noncancerous tumors may develop in the ear canal, blocking it and causing hearing loss and a buildup of earwax. Such tumors include small sacs filled with skin secretions (sebaceous cysts), osteomas (bone tumors), and growths of excess scar tissue after an injury (keloids). The most effective treatment is surgical removal of the tumor. After treatment, hearing usually returns to normal.

 

Basal cell and squamous cell cancers are common skin cancers that often develop on the external ear after repeated and prolonged exposure to the sun. When these cancers first appear, they can be successfully treated by removing them surgically or by applying radiation therapy. More advanced cancers may require surgical removal of a larger area of the external ear.

 

Ceruminoma (cancer of the cells that produce earwax) develops in the outer third of the ear canal and can spread. Ceruminomas have nothing to do with earwax buildup. Treatment consists of removing the cancer and the surrounding tissue surgically.