The following are the more common signs and symptoms of otitis externa:

• Otalgia 
• Erythema
• Pruritus
• Fluid discharge from the ear (pus)
• Hearing impairment
• Swelling of the affected ear

• Cervical Lymphadenopathy

  If there is cellulitis or cervical lymphadenopathy, oral antibiotics are indicated. Patients with systemic symptoms need same-day ENT review and may need admission for intravenous antibiotics. [patient.info]

• Pain

  Pain Medicine Give acetaminophen (e.g. Tylenol) or ibuprofen for pain relief. Local Heat If pain is moderate to severe, apply a heating pad or hot water bottle to outer ear for 20 minutes. This will also increase drainage. [web.archive.org]

  Touching or moving the outer ear will increase the pain. The eardrum may be hard to see because of a swelling in the outer ear. The eardrum may have a hole in it. This is called a perforation. [nlm.nih.gov]

  The ear canal has an abundant nerve supply, so the pain is often severe enough to interfere with sleep. [en.wikipedia.org]

  A 64-year-old diabetic male patient is described who presented with left ear pain and discharge for two months and did not respond to ordinary treatment. The patient also noticed a progressive facial weakness on the same side. [ncbi.nlm.nih.gov]

  The pain generally is not made significantly worse by manipulation of the external ear. [awoosh.com]

• Fever

  Fever, irritability, otalgia, and hearing loss are also often present. Infection can be serious and may lead to sepsis, sigmoid sinus thrombosis, and intracranial abscess if not treated appropriately. [oxfordmedicine.com]

  A 19-year-old woman presented to our Emergency Department with a chief complaint of fever, ear pain, and generalized weakness. She was noted to be in septic shock, with left neck erythema and swelling. [ncbi.nlm.nih.gov]

  Acetaminophen decreases pain and fever. It is available without a doctor's order. Ask how much to take and how often to take it. Follow directions. Acetaminophen can cause liver damage if not taken correctly. [drugs.com]

  Also give him a call – according to his guidelines – if your baby develops a fever. [babycenter.com]

• Varicella-Zoster Virus Infection

  Ramsay Hunt syndrome is a rare complication of herpes zoster in which reactivation of latent varicella zoster virus infection occurs in the geniculate ganglion, causing otalgia, auricular vesicles and peripheral facial paralysis. [ncbi.nlm.nih.gov]

• Ankylosis

  Septic arthritis of the temporomandibular joint (TMJ) is a very rare complication of otitis externa that can lead to ankylosis and destruction of the joint. [ncbi.nlm.nih.gov]

• Pruritus

  There was no difference in improvement of OTI-3 between groups at any time point, whereas Group A cytology scores and pruritus improved significantly more by Day 7 (P 0.0026 and P 0.0294, respectively). [ncbi.nlm.nih.gov]

  Ear discomfort can range from pruritus (itching) to severe pain that is worsened by motion of the ear, e.g. chewing. Discharge from the ear varies between patients and may give a clue to the cause of the condition. [dermnetnz.org]

  – Ear canal pruritus or ear pain, often severe and exacerbated by motion of the pinna; feeling of fullness in the ear; clear or purulent ear discharge or no discharge – Otoscopy (remove skin debris and secretions from the auditory canal by gentle dry [medicalguidelines.msf.org]

  Initially it is characterized by a scant, odorless secretion as well as mild discomfort and pruritus associated with modest erythema. [aafp.org]

• Otalgia

  Clinical efficacy, in terms of otalgia, oedema, erythema and tenderness of the external auditory canal, was assessed before packing was applied and at follow up on the 3rd and 7th days of presentation. [ncbi.nlm.nih.gov]

• Tinnitus

  History Patients with otitis externa (OE) may complain of the following: Otalgia, ranging from mild to severe, typically progressing over 1-2 days Hearing loss Ear fullness or pressure Tinnitus Fever (occasionally) Itching (especially in fungal OE or [emedicine.medscape.com]

  It is commonly seen in swimmers, particularly in the summer months.1 The most frequent symptoms are discharge, pain, hearing loss, itching, and tinnitus. [mdedge.com]

  There is a history of increasing otalgia with or without: custard-like, thick ear discharge conductive hearing loss tinnitus dizziness or dysequilibrium (sometimes true vertigo) It is important to note any significant risk factors for severe AOE or development [entsho.com]

  Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. 2014 Oct;151(S2):S1-40. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Kumar KA, Kramper M, Orlandi RR, Palmer JN, Patel, ZM, Peters A, Walsh S, Corrigan MD. [choosingwisely.org]

  Patients may also have the following signs and symptoms: Otalgia - Ranges from mild to severe, typically progressing over 1-2 days Hearing loss Ear fullness or pressure Erythema, edema, and narrowing of the EAC Tinnitus Fever (occasionally) Itching (especially [emedicine.com]

• Ear Discharge

  Acute diffuse otitis externa is the commonest diagnosis made with symptoms ranging from ear pain, ear discharge, hearing loss and itchiness. Most patients were treated empirically with significant success within first two visits. [ncbi.nlm.nih.gov]

  – Ear canal pruritus or ear pain, often severe and exacerbated by motion of the pinna; feeling of fullness in the ear; clear or purulent ear discharge or no discharge – Otoscopy (remove skin debris and secretions from the auditory canal by gentle dry [medicalguidelines.msf.org]

  Symptoms include temporary hearing loss, ringing or buzzing in the ears, discharge, and bleeding from the ear. In rare cases, necrotizing (malignant) otitis externa occurs. [healthline.com]

  Symptoms of a perforated eardrum may include: Hearing loss Pain in the ear Discharge from the ear Ringing in the ear A perforated eardrum will usually heal on its own in around two months. During this time, no liquid should enter the ear. [ada.com]

• Ear Fullness

  History Patients with otitis externa (OE) may complain of the following: Otalgia, ranging from mild to severe, typically progressing over 1-2 days Hearing loss Ear fullness or pressure Tinnitus Fever (occasionally) Itching (especially in fungal OE or [emedicine.medscape.com]

  Other symptoms include itching, ear fullness, hearing loss, or jaw pain. Canal inflammation is reproduced by pain from pressing on the tragus or pulling the pinna of the ear. (See photos.) [cdn.journals.lww.com]

  Patients may also have the following signs and symptoms: Otalgia - Ranges from mild to severe, typically progressing over 1-2 days Hearing loss Ear fullness or pressure Erythema, edema, and narrowing of the EAC Tinnitus Fever (occasionally) Itching (especially [emedicine.com]

• Hearing Problem

  If you still have hearing problems after treatment, have your hearing tested by an audiologist. [asha.org]

• Cellulitis of the Face

  Severe infections may cause lymphadenitis or cellulitis of the face or neck. [emedicine.com]

  mixture of isopropyl alcohol and acetic acid) Systemic treatment: oral ciprofloxacin Indications Immunosuppression Diabetes mellitus Severe otitis externa with cellulitis of the face and neck Topical administration of antibiotics is not possible (e.g [amboss.com]

• Headache

  Atypical skull base osteomyelitis arising from the sphenoid or occipital bones without associated external otitis occurs much less frequently and initially may have headache as the only symptom. [ncbi.nlm.nih.gov]

  At 10 weeks, the patient remained well, with no neurological deficit and no residual ear symptoms, and CT demonstrated complete resolution of the intracranial abscesses. ear nose and throat/otolaryngology bone and joint infections otitis neurosurgery headache [casereports.bmj.com]

  Symptoms of Otitis Media and Otitis Externa Otitis Media: The following are some of the most commonly observed symptoms of Otitis Media, especially in children: Intense earache Headache Fever Sense of fullness in the ear Leaking of fluid from the ear [sinuswars.com]

  This is considered a medical emergency, with symptoms including: severe ear pain and headaches, especially at night ongoing ear discharge facial nerve palsy (drooping of the face) on the side of the affected ear exposed bone in the ear canal A doctor [healthline.com]

• Cranial Nerve Involvement

  Nine patients had cranial nerve involvement. Twelve of 15 patients treated with medical therapy recovered, as did 11 of 12 patients that underwent surgery. [ncbi.nlm.nih.gov]

  Physical exam findings include otorrhea, granulation tissue in the external auditory canal, tenderness and swelling of the mastoid process, fever, and cranial nerve involvement. [emdocs.net]

  Acute otitis externa (AOE) can progress to necrotising otitis externa (NOE), which is an oseteomyelitis of the temporal bone and skull base, sometimes with cranial nerve involvement. [entsho.com]

  If left untreated it can lead to cartilage and bone involvement with adjacent cranial nerve involvements. Can be seen in diabetics and in immunocompromised patients. [gloshospitals.nhs.uk]

  nerve involvement; patient with diabetes mellitus or immunocompromise, elevated erythrocyte sedimentation rate, findings on computed tomography Medical emergency with high morbidity rate and possible mortality; warrants emergent consultation with otolaryngologist [aafp.org]

• Cranial Neuropathy

  This is particularly important in patients with cranial neuropathies and CT finding of adjacent structural involvement that correlate with adverse prognosis. [ncbi.nlm.nih.gov]

  neuropathies (CN VII, IX, X, XI and XII) as the disease becomes more erosive and spreads along the skull base. [entsho.com]

Patients suspected with otitis externa are brought to the physician for initial evaluation of the outer ear for evident signs. An otoscopic examination is then conducted to see the inner canal and the condition of the tympanic membrane. In complicated cases of otitis externa, patients are usually referred to an otolaryngologist  for further evaluation and management.

Sample of secretions or ear debris may be taken for laboratory culture and sensitivity testing to determine the ideal antibiotics to be used in case the preliminary antibiotics prove to be ineffective. Imaging technique with computed tomography (CT) of the skull may be implored to elucidate the bony erosions with necrotizing cases of malignant otitis externa [7]. Magnetic Resonance Imaging (MRI) is indicated where suspected deep soft tissue involvement is entertained for better visualization [8].

• Pseudomonas

  When sterile saline drops were applied to bacterially contaminated otowicks, the penetrating drops displayed bacterial growth on agar, indicating that pseudomonas penetrated through the otowick. [ncbi.nlm.nih.gov]

• Trichophyton Rubrum

  Ginter‐Hanselmayer, Trichophyton rubrum in the external auditory meatus, Mycoses, 47, 1‐2, (85-86), (2004). Peter S. Roland, Francis D. Pien, Craig C. Schultz, Dan C. Henry, Peter J. Conroy, G. Michael Wall, Rekha Garadi, Sheryl J. Dupre, Susan L. [doi.org]

Majority of otitis externa is treated medically while some cases may require surgical drainage as a treatment option.

These are the medical modalities available for the treatment of otitis externa:

• Analgesics: Patients may benefit from pain relievers like naproxen and ibuprofen. In severe cases of otitis externa, narcotics may be given to subdue the pain [9].
• Antibiotics: This is the mainstay on the treatment of otitis externa. Antibiotic therapy may be taken orally, eardrops form or in combination where the cure rate reaches 87-97% in uncomplicated case [10].
• Steroids: Severe inflammation may be controlled by the oral intake of steroids
• Antifungals: Fungal coinfection with otitis externa may need antifungal medications.
• Acidic solutions: Ear drops that may restore the normal pH of the ear to fend off invading bacteria.

The majority of otitis externa patient will resolve within 48-72 hours without complication after the administration of pharmacotherapy. Full recovery is usually expected within 7 to 10 days. Surgical drainage and debridement may be necessary to drain abscesses in the ear.

Untreated local infections may lead to malignant otitis externa which may complicate morbidity and cause mortality in severe forms. The necrotizing form of malignant otitis externa may reach a mortality rating of 20% especially among immune-compromised hosts and may even reach 50% if no medical interventions are done.

Complications

Otitis externa may give rise to any of the following given medical complications:

• Temporary auditory disturbance: Temporary hearing loss may be experienced during the inflammatory process which is usually due to impacted cerumen. This could resolve spontaneously within one week.
• Cellulitis: The uncontrolled spread of bacteria in contiguous structures like the face may sometimes occur. 
• Chronic otitis externa: Acute otitis externa with recurrent symptoms beyond 3 months becomes chronic otitis externa. This is caused by tougher bacterial strain which may be resistant to treatment, an allergic response, or a coinfection with a fungus.
• Necrotizing infection: The inward spread to the deeper tissue and the bones is severe complication of otitis externa which can cause mortality.
• Spread of infection: The uncontrolled infection may spread to the brain and cause abscess.

The most common cause of otitis externa is retained water in the ear that breeds the bacterial pathogen. Any break in the integrity of the skin of the ear canal can lead to the infection of the ear. Abrasions happen with frequent scratching, chronic use of ear piece and the ungentle application of cotton swabs during ear cleaning.

The accumulated cerumen may hold moisture and propagate the growth of bacterial organisms that may lead to infections. The majority of otitis externa is caused by bacterial infection; however, fungal (otomycosis) and psoriatic etiology may rarely initiate the disease process [1].

The most common pathogen in otitis externa is Pseudomonas aeruginosa representing 38% of cases followed by Staphylococcus species, anaerobes and gram-negative organisms [2].

In the United States, otitis externa has been recorded across all states with an average incidence of 4 cases per 1000 population per year [3]. Infection of the external ear abounds during the summer season where it’s warm and humid and presumably because water activities are common during this time [4]. Otitis externa are more prevalent in tropical countries than in temperate countries.

The disease affliction peaks at 7–12 years of age and is also common among young adults. The prevalence of otitis externa slightly peaks again beyond the age of 65 years old because of comorbid factors like diabetes and rheumatoid arthritis, and there is a large sector of elders that uses hearing aids which can propagate the infections. Patient with allergic rhinitis and asthma are more prone to otitis externa [5].

The pathophysiology in the development of otitis externa can be divided into four mechanisms of origin:

Obstructive: The accumulation of cerumen may accumulate water and moisture causing a maceration of the outer skin layer which invites bacterial invasion.

Drying: The absence of cerumen and loss of natural moisture of the ear canal skin due to frequent ear cleaning can cause fissuring and thinning of the skin membranes. The compromised skin layer may invite invading bacteria to cause the infection.

Trauma: Any break in the skin layer due to trauma from cotton wabs, fingernails or instruments may cause abrasion and eventual infection of the ear canal.

Alteration of skin natural pH: Patient on radiotherapy, chemotherapy and on chronic steroids use can alter the skin’s pH making it less resistant to bacterial invasion. Immuno-compromised patients may develop a severe necrotizing form of infection known as malignant otitis externa [6].

The best way to prevent water from accumulating in the ear canal is to wear ear plugs and swimming caps during swimming and diving activities. Practice tilting of one’s head in both directions after shower and swimming to rid-off excess water from both ears. Cleaning of ears must be done in moderation in up to once weekly to prevent the drying of the ear canal.

Otitis externa or outer ear infection is an infection of the outer ear canal. Patients must observe strict compliance in the intake of antibiotics to avoid antibiotic resistance of bacterial infection. One must call the attention of the attending physician if no improvements are observed after 3 days of treatment to merit reevaluation of treatment and prevent serious complications. Any notable discharges must also be reported to proper medical authorities for further investigation and evaluation.