The following symptoms and complaints may indicate otitis externa (ear canal inflammation):
Usually acute onset within 48 hours. Leading symptoms
- Otalgia – severe pain in the pinna and ear canal, especially when speaking and chewing (unilateral, rarely bilateral ear pain (10%)).
- Pressure painful tragus (tragus pressure pain; as tragus is the small cartilaginous mass on the auricle, which lies just before the auditory canal; pain when pulling on the auricle).
- Pruritus (itching) in the ear
Possible accompanying symptoms
- Otorrhea (ear running; discharge of mucous secretion or pus/pus).
- Inflammation in the area of the entrance to the ear canal or the auricle/edematous (swollen) auricle
- Flaking
- Hearing loss, possibly hearing loss
- Lymphadenopathy (lymph node enlargement)
Differential diagnostic criteria for inflammation of the auditory canal.
Otitis externa diffusa | Otitis externa circumscripta | Otitis externa mycotica (moist otomycosis) | |
Course | long, recurrent | short | long |
General condition | Often not disturbed, no fever | disturbed, fever | not disturbed |
Pain | moderate to severe | strong, pulsating | itching only |
Secretion (otorrhea) | Watery, sweetish-bland | purulent | friable |
Clinical features | as described above |
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Pathogen | Pseudomonas aeruginosa (20-60%), also Staphylococcus aureus (10-70%). | Hemolytic staphylococci, frequently also Staphylococcus aureus | Aspergillus species; frequently also Candida albicans |
Notice: In rare cases, viral diseases of the external ear also occur (e.g., herpes zoster oticus and herpes simplex). The following symptoms and complaints may indicate otitis externa maligna:
- Otalgia – severe pain in the pinna and ear canal, especially when speaking and chewing (unilateral, rarely bilateral ear pain (10%)).
- Otorrhea, fetid (smelly).
- Granulations in the auditory canal
- Failures of cranial nerves (esp. facial nerve).
- Reduced general condition
Decision algorithm: acute otitis externa requiring referral to an otolaryngologist: evidence-based acute otitis externa referral score (EAR score).
Risk factors | Score | |
One of these characteristics | Age > 65 | 1 point |
Chemotherapy or radiotherapy (radiation therapy) | ||
Well-controlled diabetes mellitus | ||
Otitis external recurrence | ||
Either … | Immunosuppression (suppression of the immune system). | 2 points |
…or | Poorly controlled diabetes mellitus (HbA1c > 8.0% ). | |
Duration of treatment | 3 points | |
Either. | Not scheduled to present again in the first 10 days of therapy | |
…or | Persistent otitis externa despite 14-day treatment. | |
Red flags (warning signs) | ||
One of these factors | Cranial nerve palsy | 5 points |
Excessive ipsilateral ( “located on the same side or half of the body) headache | ||
Erythema (areal redness of the skin) or swelling of the auricle or face | ||
Completely stenosed (constricted) ear canal (speculum cannot be inserted) |
Interpretation
- 0 points: Need for specialist treatment unlikely.Patient can be discharged after initial consultation with prescription and instructions about warning symptoms (here: Red Flgs).
- 1-2 points: Active monitoring is required. Patient should be followed up by general practitioner during and after treatment.
- 3-4 points: Urgent referral to an otolaryngologist within twelve to 48 hours is advisable.
- ≥ 5 points: Immediate emergency referral to ENT physician.
The the EAR score achieved a sensitivity of 100% and a specificity of 90%, related to bringing up complications requiring specialist treatment. The negative predictive value was 100%.