288
Otitis Externa
CHARLES W. REES, M.D., San Diego
SUMMARY
Otitis externa is a widespread condition
which may occur in many different forms.
Allergic reactions, bacteria, pathologic
changes secondary to seborrheic dermatitis,
and fungi, singly or in association with each
other, are among the causative factors con-
sidered.
In the treatment of this condition, the
diversity of causative factors which may be
present must be recognized and evaluated;
after one factor has been eliminated, another
often remains to be conquered. The apparent
confusion of reports regarding etiology and
treatment is in fact due to confusion regard-
ing the fundamental nature of the condition.
Good results usually can be obtained by care-
ful evaluation of the factors in each case and
adaptation of treatment to the circumstances.
OTITIS externa is the common name given to
inflammatory conditions of the external ear and
external auditory canal. Incidence of the disease is
high in otological practice. Dermatologists have
contributed a great deal to knowledge of the condi-
tion, and in treatment of it the two specialties over-
lap. As there may be multiple etiological factors
present, treatment should be directed to the eradica-
tion of the basic as well as secondary or super-
imposed infection.
In the adult, the external auditory canal averages
11/4 inches in length an'd is directed inward and
forward. The inner one-third of this canal is sup-
ported by bone and the outer two-thirds by cartilage.
The skin which lines the canal covers also the outer
surface of the tympanic membrane. It is thick in
the cartilaginous portion and contains hair follicles
and sebaceous glands, the latter extending for some
distance along the posterior and superior walls of
the bony portion of the canal.
External otitis is often a painful condition. Au-
thorities differ considerably on the subject of the
nerve supply of the external ear. Eggston and Wolff4
state that the confusion is due to three factors: (1)
the anatomic variation in different individuals, (2)
the fact that data have been collected from clinical
From the Department of Otolaryngology, Rees-Stealy
Clinic.
Presented before a Joint Meeting of the Sections on Eye,
Ear, Nose and Throat and Dermatology and Syphilology
at the 77th Annual Meeting of the California Medical Asso-
ciation, San Francisco, April 11-14, 1948.
Vol. 70, No.
observation of cases of herpes zoster, referred pain,
and similar affections and not from anatomic dis-
section, and (3) the fact that the areas supplied by
the various nerves overlap each other considerably.
Sensory innervation is supplied by the auriculo-
temporal nerve of the mandibular branch of the
trigeminal nerve, the auricular branch of the vagus
nerve, and the great auricular nerve from the second
and third cervical nerves.
The relative incidence of external otitis in men
and women has not been determined. The recent
war has given a distorted picture in this respect
because of the large groups of men transplanted
from their normal environment to hot, moist cli-
mates where external otitis is very common and
often severe. No age group is exempt but the
preponderance of cases is found among young
adults.
ETIOLOGY
Many factors play a part in inflammatory reac-
tions of the external ear. Allergic reactions, bac-
terial infection, pathologic changes secondary to
seborrheic dermatitis, and fungous growths have
been named as the usual causes. Other possible
causes such as extremes of temperature, either heat
or cold, radiant energy effects which may cause
profound tissue changes, and chemical irritations
not associated with hypersensitiveness or allergy,
will not be included in this discussion.
Allergic external otitis is due to exposure to an
allergen to which the individual is hypersensitive.
It may be acute or chrontic. The acute stage is
usually manifested by an exudative type of eczema-
toid dermatitis which may become chronic with
thickening and desquamation of the skin. Cosmetics
may produce these reactions; fingernail polish has
been reported as a frequent offender, as have scalp
lotions and perfumes. Sulfonamide and penicillin
preparations, as well as many preparations used
routinely in otologic practice, should always be re-
garded as possible causes of this condition.
External ear infections may be classified as pyo-
genic, non-pyogenic, and mycotic.5 Impetigo con-
tagiosa not infrequently invades the external audi-
tory canals of children and may be found in adults.
The lesions are usually typical and have been attrib-
uted to the action of streptococci and staphylococci.
A deeper invasion of the skin produces pyogenic
dermatitis which may affect the underlying cartilage.
These reactions are occasionally severe.
A circumscribed inflammatory reaction may de-
velop with localized abscess. The lesions may be
single or multiple and have a pronounced tendency
to recur. Severe pain in such cases is due to localized
April, 1949 OTITIS EXTERNA
swelling in tissues in which there is little room for
expansion; well-developed furunculosis causes a
great deal of distress. It is occasionally difficult to
differentiate these reactions from those of acute
otitis media. They may even be associated with
disease of the middle ear as secondary skin lesions
which develop as the result of contamination by
infected secretions from the middle ear cavity.
Acute cellulitis of the external ear may follow any
break in tissue which permits infection to gain
entrance; a break in the skin of the ear canal
caused by the common practice of scratching or by
an unnoticed insect bite frequently provides a portal
of entry.
Erysipeloid reactions and true erysipelas of this
area may be encountered. These acute reactions are
usually demarcated and present the usual picture of
acute lymphangitis.
In inflammatory reactions of the external ear, in
which bacterial invasion of the tissues has occurred,
the factors are many and diverse. Williams, Mont-
gomery, and Powell13 found by special culture meth-
ods that streptococci were frequently present in
otitis externa and expressed the belief that these
organisms were of etiologic significance. Beach and
Hamilton' reported that in 65 of 69 cases observed
on a South Pacific island the infection was due to
Pseudomonas aeruginosa; of the remaining four
"one showed a fungous growth and three a mixed
type of infection composed of streptococci, staphylo-
cocci, and diphtheroids." Senturia and Broh-Kahn5
expressed the opinion that "the high degree of cor-
relation between the presence of Pseudomonas or-
ganisms in the ear canal and the existence of certain
types of external otitis suggests some relationship
between these organisms and the disease." They
further stated that this organism can almost always
be isolated from the ear canals of patients with
external otitis and not from the ears of normal
individuals. P. aeruginosa is a particularly frequent
water contaminant in the tropics; it is found also,
although less often, in temperate climates.
Seborrhea is a frequent influencing factor in
reactions in the external auditory canal. The diction-
ary defines seborrhea as a "chronic disease of the
sebaceous glands marked by the occurrence of an
excessive discharge of sebum from the glands." It
does not occur until the age of puberty. According
to Becker and Obermayer,2 Unna believed moroccus
was the causative agent in seborrhea, whereas Moore,
Kyle, and Engman2 have named Pityrosporum ovale
as the infecting organism. The cause of seborrheic
dermatitis is not known. Most investigators agree
that because of constitutional peculiarities, the skin
glands of some individuals provide a suitable me-
dium for the growth of saprophytes or secondary
invaders. Many of the cases of external otitis
encountered in office practice in temperate climates
are due to seborrheic dermatitis complicated by local
cellulitis resulting from bacterial invasion of the
tissue surrounding the sebaceous glands. This proc-
ess may begin as an infection of non-resistant
289
sebaceous glands. The organisms involved in the
secondary reaction are likely to be streptococci,
staphylococci, and diphtheroids. Maceration of epi-
thelium by water or perspiration is a common pre-
disposing factor and in some of these cases the
superficial epithelium harbors a parasitic growth of
fungus.
Seborrheic dermatitis may be confused occasion-
ally with psoriasis, one of the most common of all
dermatoses. Psoriasis often affects the scalp and
may extend down to the postauricular area. The
differential diagnosis is made by the absence of
similar lesions at sites of predilection of psoriasis,
the nature of the lesion and of the scales, which in
seborrheic dermatitis are thinner and less adherent
than in psoriasis, and by the absence, upon removal
of scale, of minute bleeding points which are preseni
in psorlasis.
OTOMYCOSIS
Otitis externa in which the causative agents are
thought to be molds is that type of inflammatory
disease of the external ear referred to as otomycosis.
Three types of molds may be encountered in such
cases: (1) budding forms, (2) filamentous forms,
and (3) higher bacterial forms. Higher bacterial
forms of molds possess properties of both bacteria
and molds. Classification of them is confused and
there is a synonymity of names. "Bergey's classifica-
tion (1934) contains 70 species under the genus
Actinomyces."7 They will not be considered here
except to state that the primary lesions of actino-
mycosis may occur on the external ear or in the
external auditory canal and that these structures
may be invaded by extension from a nearby focus.
Some otologists are convinced that the molds
found in external canal lesions are definite patho-
gens and describe the condition as being caused by
the molds found to be present. Whalen'2 stated that
species of Monilia, Aspergillus, Penicillium, and
Achorion have been found. Many believe that if
molds are to be considered pathogenic it must be
with the qualification that the site and conditions
are predisposing factors. Forms of budding and
filamentous fungi may be cultured from the surface
of normal skin and the question arises whether they
can be named as the cause of the disease under
discussion. Positive demonstration of molds as the
primary invaders in cases of otitis externa is ex-
tremely difficult. McBurney and Searcy9 stated that
"the relationship of these [molds] as primary in-
vaders has not been established since animal inocu-
lations with the isolated fungi have almost invar-
iably yielded negative results." Chisolm and Sutton3
thought that "in the ear the fungus is probably never
a primary invader but it may persist after the pri-
mary condition has disappeared or become masked
by it." Lewis and Hopper8 report that auto-inocula-
tion experiments with Aspergillus were attempted on
several occasions but were not successful. The pres-
ence of fungi in infected auditory canals can be
demonstrated in fewer than a majority of cases.
Simon" treated 90 male patients for external otitis
290 CALIFORNIA MEDICINE Vol. 70, No. 4

in a tropical climate. In only 21 per cent of these to the suspicion that none is satisfactory. The sug-
cases did cultures reveal the presence of a fungus. gested remedies are perhaps numerous because the
The author of this presentation studied material causative factors are varied and the treatment must
from infected auditory canals in 100 consecutive be selective to be effective. Seborrheic dermatitis,
cases among naval personnel in the hot, moist cli- bacterial cellulitis, and fungous dermatitis may be
mate of the Philippine Islands. By using the method present in varying degree. Although seborrheic der-
of Whalen12 of examining a smear treated with 2 matitis may be the fundamental factor in many
per cent sodium sulfite with methylene blue added, cases, the other factors must also be evaluated.
molds were identified in only 19 cases. Culture and Pseudomonas organisms respond readily to sub-
fermentation studies were not attempted. Although stances containing the acetate radical. Acetic acid,
it is possible that in some of the cases fungi were 2 per cent, is helpful, as is cresatin (metacresyl
the primary invaders and were later crowded out acetate). Gill5 considers the latter preparation a
by bacteria, the fact that many of the patients in potent fungicide, especially when reinforced by the
whom the fungi were not demonstrated were seen addition of thymol. Pseudomonas aeruginosa is sen-
during the early and acute stages of the disease sitive also to the action of streptomycin. Senturia
rather belies this possibility. It would appear that and Broh-Kahn5 reported success with an ointment
in most instances factors other than fungi were containing 5 mg. of streptomycin per grarn of oint-
responsible for the condition, and that molds when ment base, in cases which showed a predominance
present represented a parasitic growth. It is not to of these organisms. Hayes and HallP consider a new
be doubted that actively growing fungus contributes compound, dibromsalicylaldehyde, to be especially
to the infectious process and is responsible for some effective against Gram-negative organisms including
of the clinical manifestations. Under conditions Ps. aeruginosa and also against fungi. Its use is
favorable to such growth the vegetative portion of a recommended in solution or powdered form. Favor-
fungus increases whereas under adverse conditions able response to the topical and systemic use of
there is a tendency toward production of spore forms sulfonamide preparations is occasionally obtained.
which are resistant to all forms of treatment. Inva- The topical application of penicillin preparations
sion of the epithelium causes itching and discomfort. has been reported to be effective when Gram-positive
The resulting reactions may be mild or severe; ex- organisms predominate. The author has not found
foliation and denudation may be followed by ulcera- this method of much value. The possibility of com-
tion and erzematoid dermatitis. plicating the picture with allergic reaction to anti-
biotics, when these are used, must be borne in mind.
TREATMENT Dyes have been used but rarely with success.
Treatment of otitis externa must be directed to- After the acute inflammatory reaction subsides
ward the fundamental causative factor and must be the seborrheic dermatitis, if present, remains to be
carefully adapted to the severity of the dermatitis treated. Sulfur preparations have proven of value
present. The treatment of external ear lesions in these cases. Ichthyol has been used, and precipi-
caused by allergic reaction is primarily a problem tated sulfur may be applied in an ointment. Ammo-
of determining the irritant or allergen to which the niated mercury and salicylic acid have been found
patient is sensitive and eliminating this factor. Im- efficacious. Some dermatologists stress the impor-
petigo contagiosa is highly infectious and precau- tance of a greaseless base in ointments for this use.
tions must be taken against extension to other The avoidance of moisture in the area is important
persons. Thorough cleansing with removal of crusts and general hygienic measures should be instituted.
is essential; antibiotic preparations applied to a Energetic treatment of the surrounding scalp is es-
clean base are effective. Pyogenic dermatitis is sential, as this area often acts as a focus of infection.
treated as impetigo is treated, with thorough cleans- Vitamin therapy cannot be expected to produce
ing; the spreading cellulitis is treated as such with results unless a true deficiency exists.
wet dressings; sulfonamides or penicillin may be Roentgen therapy is widely regarded as a valuable
helpful also. Furunculosis requires medication for form of treatment for many dermatoses. The ele-
relief of pain; if the infection is severe such relief ment of danger in its application limits its use to
will be inadequate at best. For the localized reaction those who have had special training in it. Roentgen
and in the acute stage of diffuse swelling from rays are not appreciably bactericidal but they are
cellulitis, loose packing and wet dressings with supposed to induce increased antibacterial activity
aluminum acetate have proven most satisfactory in of the tissues by disintegrating leukocytes and re-
the author's experience. Full strength or one-half leasing antibacterial substances. Furunculosis, ery-
strength Burow's solution may be used. Antibiotics sipelas and impetigo have been treated in this
often produce spectacular results if adequate blood manner. Sebaceous glands are sensitive to roentgen
levels are obtained and maintained. Surgical inter- rays and' the margin of safety is wide in the treat-
vention is to be avoided if possible. Erysipelas ment of hyperactivity of these glands. Excessive
responds to antibiotic therapy and to specific sera. activity of the glands may be curbed by appropriate
The large remaining groups of cases of external irradiation before surrounding cutaneous tissues are
otitis present a complicated therapeutic problem. affected. Any beneficial result is probably due to
The nuimber and variety of suggested remedies leads control of the underlying seborrhea.
April, 1949 OTITIS EXTERNA
REFERENCES
1. Beach, E. W., and Hamilton, L. L.: Tropical otitis ex-
terna; ear fungus, U.S. Nav. Med. Bull., 44:599 (March),
1945.
2. Becker, S. W., and Obermayer, M. D.: Modern der-
matology and syphilology, Philadelphia, Lippincott, 2nd ed.,
1947, p. 238.
3. Chisolm, J. J., and Sutton, A. C.: Otomycoses; report
of 9 cases treated with potassium iodid, Arch. Otolaryngol.,
2:543 (Dec.), 1925.
4. Eggston, A. A., and Wolff, Dorothy: Histopathology of
the ear, nose and throat, Baltimore, Williams & Wilkins Co.,
1947, p. 81.
5. Gill, W. D.: Diseases of the external ear, in Jackson, C.
and Jackson, C. L., Diseases of the nose, throat, and ear,
Philadelphia, Saunders, 1946.
6. Hayes, M. B., and Hall, C. F.: The management of oto-
genic infections, Tr. Am. Acad. Ophth. & Otolaryngol., 1946-
1947, p. 149.
7. Jordan, E. O., and Burrows, Wm.: A textbook of gen-
eral bacteriology, Philadelphia, Saunders, 12th ed., 1938, p.
500.
8. Lewis, G. M., and Hopper, Mary E.: An introduction to
medical mycology, Chicago, Year Book, 1939, p. 151.
9. McBurney, R., and Searcy, H. B.: Otomycoses, Ann.
Otol. Rhin. & Laryng., 45:988 (Dec.), 1936.
10. Senturia, B. D., and Broh-Kahn, R. H.: The use of
streptomycin in the treatment of diffuse external otitis, Ann.
Otol. Rhin. & Laryng., 56:1 (March), 1947.
11. Simon, E.: Otitis externa and its treatment, Arch.
Otolaryngol., 42:123 (Aug.), 1945.
12. Whalen, E. J.: Fungus infection of the external ear,
J.A.M.A., 111:502 (Aug. 6), 1938.
13. Williams, H. L., Montgomery, H., and Powell, W. N.:
Dermatitis of the ear, J.A.M.A., 113:641 (Aug. 19), 1939.
Discussion by FREDERICK G. Novy, JR., M.D., Oakland
Otitis externa is a vexing problem to both the otologist
and the dermatologist. Dr. Rees has emphasized that the
causes may be multiple and that many agents can produce
dermatitis of the external auditory canal.
The term fungous infection of the ears is a misnomer.
This has been brought out by Dr. Rees in his paper and has
been confirmed by the investigations in the tropics during
the war by Syverton, Hess, and Krafchuk (Arch. Otolaryng.,
43:213, March 1946). These authors and others, such as Sal-
vin and M. L. Lewis (External otitis with additional studies
on the genus Pseudomonas, J. Bacteriol. 51:495-506, April,
1946), found in many cases of infection of the external audi-
tory canal that the offending organism was usually Pseudo-
291
monas aeruginosa (bacillus pyocyaneus). In both of these
series of cases, when fungi were isolated from the external
auditory canal, they were of the type which ordinarily are
considered non-pathogenic. The high incidence of pyocy-
aneus infection can well explain why ordinary methods of
treatment with the usual antiseptic agents have not been
satisfactory since pyocyaneus is notoriously resistant to or-
dinary antiseptic solutions.
It is my feeling that the chronic recurring external otitis
is nearly always on the basis of a seborrheic dermatitis in-
volving the scalp, ears and occasionally other areas. At times
superimposed upon this seborrheic dermatitis there is a sec-
ondary infection explaining the clinical exacerbation. For
this reason the scalp should always be treated for the se-
borrheic dermatitis and after the acute exacerbation subsides
the external auditory canal should also be treated on this
basis. There are some investigators who feel that seborrheic
dermatitis is due to a Vitamin B deficiency. Certainly it is
true that in some of the chronic cases the patients apparently
show improvement with large doses of Vitamin B and, in
addition, injections of crude liver extract.
In regard to treatment in the past, weak solutions of acetic
acid and liquor aluminum acetate (Burow's solution) have
been fairly satisfactory in the chronic cases. Recently there
have been enthusiastic reports on the use of streptomycin by
Calloway (Pseudomonas aeruginosa infection of the ear
treated with streptomycin, Arch. Dermat. & Syph. 55:257,
Feb., 1947). He used a solution containing 2,500 units per
cc. as a wet dressing. Others have also reported favorably
on this drug.
A word of warning should be raised concerning the use
of streptomycin locally because there have been several re-
ports of a severe localized dermatitis occurring in the nurs-
ing personnel making up solutions with this drug. Recently I
had the opportunity of talking with the medical department
of a large Veterans Hospital devoted to the care of tuber-
culous patients where investigative work with streptomycin
was being done. Over half of the nurses handling this drug
had severe dermatitis of the hands. I feel that this may be
a consideration in the use of streptomycin locally in the
treatment of various pyodermas of the skin.
Among the newer sulfa compounds that have been de-
veloped there is one known as sulfamylon which has proven
in vitro to be highly effective against bacillus pyocyaneus.
This drug may be the answer in handling severe, chronic
cases of otitis externa which are apparently due to this
organism.
Because of the complexity of etiologic factors in otitis ex-
terna, Dr. Rees' admonition to appraise the factors in each
case carefully and adapt the treatment to the situation should
be heeded.