Managing Acute Otitis Externa: The Latest Guidelines

Gordon H. Sun, MD, MS


March 02, 2016

Diagnostic Criteria for AOE

AOE (known colloquially as "swimmer's ear") is a very common condition. In 2007, the Centers for Disease Control and Prevention estimated that more than 2.4 million ambulatory care and emergency department visits in the United States (approximately 8.1 visits per 1000 population) resulted in a diagnosis of AOE.[1] In the United Kingdom, the estimated 12-month prevalence of AOE was slightly more than 1% in 1997.[2]

AOE can present with any or all of these five symptoms: otalgia, otorrhea, pruritus, hearing loss, and aural fullness, although all five need not be present to make the diagnosis. The diagnosis of AOE requires three components, incorporating symptoms, signs, and rapidity of onset[3,4]:

  • Symptoms of inflammation of the external auditory canal, including otalgia, itching/pruritus, or aural fullness;

  • Signs of inflammation of the external auditory canal, including tenderness of the tragus, pinna, or both, or diffuse ear canal edema, erythema, or both; and

  • Rapid onset of symptoms (within the previous 3 weeks) and generally within 48 hours.

Similarly, patients may have such signs as mild fever, otorrhea, cervical lymphadenitis, tympanic membrane inflammation, and cellulitis of the pinna or adjacent skin on examination, but none of these findings are mandatory for the diagnosis of AOE. Pain is considered the symptom that best correlates with the severity of AOE presentation.[4]

Second Case: Risk Factors for AOE

A 62-year-old mechanic presented to his family physician with a 2-day history of severe right ear pain and a sensation of fullness in the right ear. He denied having any fevers, dizziness, or hearing loss. The patient's medical history was significant for diabetes controlled with metformin, hypertension, and a stroke 3 years ago. He reported no history of ear surgery but did state that he had "many" ear infections as a child. The patient has used bilateral hearing aids for about 5 years with no previous difficulties. He denied using tobacco, alcohol, or illicit drugs and has no known drug allergies.

On examination, the patient appeared to be in mild discomfort but reported no respiratory distress. His vital signs were within normal limits. A fundoscopic exam was unremarkable, and extraocular movements were intact. Anterior rhinoscopy demonstrated a small nasal septal deviation but no other notable findings. Examination of the right ear revealed mild edema and tenderness of the auricle and pinna as well as severe pain when the otoscope was introduced into the external auditory canal. There was no right-sided mastoid tenderness. Right otoscopy demonstrated significant swelling of the canal, some desquamation of the canal epithelium, and copious white otorrhea. The tympanic membrane could not be visualized owing to a foreign body wedged deeply in the canal. Under otomicroscopy, the foreign body was removed and found to be a soiled tip from a cotton swab. The tympanic membrane was inflamed but otherwise intact. Examination of the left ear was unremarkable, as were the oral and oropharyngeal cavities. The neck was supple without lymphadenopathy. Cranial nerve VII function was grossly intact bilaterally.

Upon further questioning, the patient admitted to regular use, over many years, of cotton swabs to "clean out" his ears. However, he was insistent that this was the first time he had experienced these symptoms.


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