I n f e c t i o n s o f t h e Ea r

Jacob Szmuilowicz, MD, Randall Young, MD, MMM*

KEYWORDS
 Ear infections  Summary  Review

KEY POINTS
 This article is a concise review of common infections of the ear and recommended diag-
nostic and treatment options for emergency providers.
 Infections of the ear are summarized by their different anatomic compartments (outer,
middle, and inner).
 Common treatments and potential pitfalls for the treating emergency provider are
discussed.

INTRODUCTION

Infections of the ear can be broken down into 3 distinct areas, the outer, the middle,
and the inner ear. Because affected patients present with different complaints, a care-
ful history and physical examination are very important. Outer ear infections are
referred to as otitis externa; middle ear infections are referred to as otitis media,
and inner ear infections are referred to as otitis interna, but are most generally thought
of as labyrinthitis or neuronitis.

OUTER EAR INFECTIONS

Outer ear infections are described as infections ranging from the outside surface of the
head to the eardrum or tympanic membrane (TM). The authors cover 3 basic types of
outer ear infections, otitis externa (swimmer’s ear), perichondritis, and malignant otitis
externa.
Otitis Externa
Commonly referred to as swimmer’s ear, the term can be a bit misleading because the
patient does not need to swim in order to be afflicted by this infection. Most often otitis
externa is caused by a bacterial infection, but in some cases, fungi can also cause this
infection. Risk factors for otitis externa include the following: swimmers with risk

Disclosure Statement: Nothing to disclose, no conflicts to report.

Department of Emergency Medicine, Kaiser Permanente, 4647 Zion Avenue, San Diego, CA
92120, USA
* Corresponding author.
E-mail address: rjyoungmd@kaiser-ed.com

Emerg Med Clin N Am 37 (2019) 1–9

https://doi.org/10.1016/j.emc.2018.09.001 emed.theclinics.com
0733-8627/19/ª 2018 Elsevier Inc. All rights reserved.

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2 Szmuilowicz & Young

amplified by the use of earplugs, chronic dermatitis conditions (eczema, psoriasis, and
so forth), use of cotton swabs to clean their ears or those who use earplugs, and use of
potentially caustic irritants near their ears (hair dyes, hair sprays, and so forth).
The diagnosis of otitis externa is made by a careful history and physical examina-
tion. Patients will complain of pain with movement or palpation of the outer ear or itch-
ing of the ear canal. A clinician performing an examination should pay attention to pain
with manipulation of the pinna or auricle. Examination of the auditory canal via an oto-
scope will demonstrate an edematous and erythematous auditory canal sometimes
lined with pus or debris. The examination should ensure that the TM is intact because
this would alter the treatment regimen. When the findings occur in an elderly diabetic
or other immunocompromised patient, malignant otitis externa must be considered.
The most common causative organisms of otitis externa are Pseudomonas aerugi-
nosa and Staphylococcus aureus. Other organisms, however, can be involved, such
as other bacteria, viruses, and fungi. Obtaining a culture may be considered and would
be helpful if the initial treatment results in failure. In patients with a history of repeated
otitis externa treated with antibiotic drops, fungal infections should strongly be consid-
ered. The most common fungal infections include Aspergillus and Candida. In these
cases, diagnosis can be made by careful examination of the ear to look for black
fungal colonies (aspergillus) or white fungal colonies (candida).
With an intact TM, the recommended treatment of otitis externa involves the use of
topical drops, usually a topical antibiotic that may be combined with a steroid or a 2%
acetic acid otic solution. The typical antibiotic component of drops is most commonly
a quinolone or aminoglycoside, although some formularies may prefer a neomycin or
Polymyxin-B formulation. With a ruptured TM, ofloxacin otic drops1 or oral antibiotics
are the recommended treatment. By slightly lowering the pH of the external ear canal
with a 2% acetic acid solution, the environment is altered, making it inhospitable to
typical bacterial growth. The possible risk, however, is that by lowering the pH, the
slightly caustic nature of the solution can lead to trauma in the ear canal, thereby
increasing risk of an infection by the decreased barrier of the epithelium. Patients
rarely require systemic treatment with oral or intravenous (IV) antibiotics; however,
consideration should be given to patients with a toxic appearance or those with a
known immunodeficiency or who are immunosuppressed.
Key points
 Diagnosis of acute otitis externa is made by careful history and physical exami-
nation. Emergency providers should have a high level of suspicion in those who
are at risk, such as swimmers, those with chronic dermatitis, or those with recent
trauma.
 Treatment depends on whether the TM is intact.
 Antibiotic drops with or without a corticosteroid are the mainstay of treatment,
but other treatments may involve a 2% acetic acid solution.
 Systemic antibiotic therapy is rarely required.
Perichondritis
Perichondritis is an infection of the cartilage of the outer aspect (auricle) of the ear.
Perichondritis is often caused by piercings, surgery, burns, or ear trauma or overlying
skin infections. This can be complicated by patients with immunodeficiencies or dia-
betes. Patients will present with complaints of redness, pain, and swelling around the
auricle. In early stages, simple induration may be found, whereas in later stages, fluct-
uance may be palpated. In these later stages, there is often an accumulation of pus
under the surface that must be drained for infection control. If there is a foreign

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 Infections of the Ear 3

body such as a piercing that could be seeding the infection, it must also be removed.
Appropriate treatment involves both incision and drainage and antibiotic therapy. As
with other types of abscesses, antibiotic therapy alone is not sufficient once this infec-
tion has organized. The most common microbial species isolated from a perichondrial
infection is P aeruginosa.2 Antibiotic treatment choice has centered on the use of flu-
oroquinolones with ciprofloxacin oral treatment as the mainstay. Unfortunately,
because P aeruginosa is one of the notorious SPACE organisms (Serratia, P aerugi-
nosa, Acinetobacter, Citrobacter, Enterobacter cloacea), it is known to rapidly develop
antibiotic resistance, even against fluoroquinolones.3 Frequent follow-up is impera-
tive, and parenteral antibiotic therapy may be required. Treatment of perichondritis
can be very challenging and should not be considered complete in a single emergency
department (ED) visit. The patient should be referred to an otolaryngologist because
the potential complication of unsuccessful treatment can lead to lifelong
disfigurement.
Potential complications of perichondritis include reaccumulation of the abscess or
formation of a seroma in the potential space caused by the previous abscess and/or
cartilaginous destruction of the auricle caused by pressure against the cartilage result-
ing in permanent deformity of the ear (cauliflower ear).
Key points
 Diagnosis of perichondritis is made by history and physical examination. Emer-
gency providers should have a high level of suspicion in patients who have
had recent ear trauma.
 Abscess formation is a common complication and can lead to lifelong disfigure-
ment if not appropriately drained.
 Oral, or in some cases, IV antibiotics, are the mainstay of therapy. The most com-
mon causative organism is P aeruginosa.
 Referral to an otolaryngologist should always be considered because manage-
ment of a cartilaginous infection is challenging.
Malignant Otitis Externa
Malignant otitis externa is a very rare complication of the spread of otitis externa into
the mastoid and/or temporal bone causing osteomyelitis. The most common organism
that causes malignant otitis externa is P aeruginosa.4 This complication does not usu-
ally occur in those who are otherwise young and immunocompetent. It should be sus-
pected in those who are elderly or immunocompromised, such as patients with AIDS
or a relative immunocompromised state, such as diabetes or patients on chronic ste-
roids or immunosuppressive medications.
Presenting symptoms of malignant otitis externa are headache with otalgia, some-
times with vertigo and decreased hearing. Physical examination reveals an examina-
tion that is similar to what would be expected for a severe case of otitis externa, often
with purulent or foul-smelling drainage. In addition, there will likely be pain on bony
palpation of the mastoid or adjacent areas of the skull.
Confirmation of the diagnosis of malignant otitis externa is made by MRI or
computed tomographic (CT) scanning. Additional laboratory tests that can be useful
not only in diagnosis but also in monitoring of treatment include a complete blood
count and inflammatory markers, erythrocyte sedimentation rate, and C-reactive pro-
tein. Upon confirmation of the diagnosis of malignant otitis externa, immediate consul-
tation with otolaryngology should be obtained.
Treatment of malignant otitis externa typically requires prolonged IV antibiotic ther-
apy, often extending for at least 6 weeks, strict glucose control, if applicable, and

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4 Szmuilowicz & Young

hyperbaric oxygen treatment may be considered. Necrotic tissue within the external
auditory canal will likely require frequent debridement; however, bony resection is
rarely indicated. Despite aggressive treatment, mortality in malignant otitis externa
is still 10% to 20%.4

Key points
 Malignant otitis externa is a rare complication of otitis externa with a very high
mortality. It should be considered in elderly diabetic and immunocompromised
patients.
 Accurate diagnosis requires advanced imaging with either MRI or CT scan.
 The most common causative organism is typically P aeruginosa, and initial treat-
ment is with IV fluoroquinolones.
 With a confirmed diagnosis or a high level of suspicion, otolaryngology should be
immediately consulted and the patient should be hospitalized.

MIDDLE EAR INFECTIONS

The middle ear is defined by the TM and the adjacent air-containing chamber that
houses the 3 auditory ossicles. Sound waves enter the external ear and are funneled
to the middle ear, where the vibrations are then transmitted and amplified via the TM
and auditory ossicle to the inner ear. The middle ear chamber additionally communi-
cates with the eustachian tube and the mastoid air spaces. This section discusses in-
fections of the middle ear, primarily otitis media, and its associated infectious
complications, including mastoiditis and myringitis.

Otitis Media
Infection or inflammation of the middle ear is broadly known as otitis media. When
symptom onset occurs rapidly, it is called acute otitis media (AOM). Although AOM
is seen in both adults and children, it primarily seen in the pediatrics population. Chil-
dren are thought to be more susceptible to AOM because of their unique anatomy.
Shorter, immature, and more horizontally oriented eustachian tubes produce a more
favorable environment for infections.
AOM most commonly occurs in association with, or soon after, a viral upper respira-
tory infection (URI). Inflammation obstructs flow through the eustachian tube and creates
conditions favorable for middle ear infections. Streptococcus pneumoniae, nontypeable
Haemophilus influenzae, and Moraxella catarrhalis are the most commonly identified
bacterial organisms.5,6 S aureus and P aeruginosa have also been known to cause
AOM, but are generally more often associated with chronic otitis media.5,7
The diagnosis of AOM is largely based on the obtained history and physical exam-
ination. Patients presenting to the ED frequently describe a few days of URI symptoms
or a recently resolved URI, followed by sudden onset, worsening otalgia. Fever,
conductive hearing loss, and otorrhea may also be reported. Otorrhea should alert
the clinician to inspect for perforation of the TM. Regarding the pediatric population,
patients may be more irritable and fussy than usual. Holding, tugging, or rubbing
the affected ear is also commonly reported. On examination, otoscopic visualization
shows a retracted or bulging TM, and there is impaired TM mobility on pneumatic oto-
scopy. In addition, the TM may be erythematous from inflammation or yellow or white
secondary to a middle ear effusion. A complete examination of the cranial nerves
should also be performed because of their proximity to the middle ear, because
many severe complications of AOM extend beyond the confines of the middle ear
chamber.

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 Infections of the Ear 5

Of note, otitis media with effusion (OME) is a common sequela of AOM, but it is not
considered an infection. OME presents with ear discomfort, sensation of ear fullness,
or decreased hearing without pain. Symptoms may persist for weeks to months. On
examination, patients may have a middle ear effusion with little inflammatory changes
and an immobile TM on pneumatic otoscopy. As OME is not an infection, antibiotics
are not helpful, and most cases resolve spontaneously, generally without requiring
treatment, and without complications. Watchful waiting is the most common approach
to managing this condition.
Complications from AOM are relatively infrequent, but should be considered when
managing any patient with a presentation suggestive of otitis media. The most com-
mon complication is perforation of the TM. This is caused by increased pressure pro-
duced by fluid accumulation in the middle ear. Patients may describe ear pain, hearing
loss, otorrhea, tinnitus, or vertigo. Management consists of oral and topical antibiotics.
The same oral antibiotics used to cover the initial AOM infection, as discussed later in
this section, are appropriate, and topical antibiotics, such as ofloxacin, may also be
included. In most cases, TM perforation heals within a few weeks without needing
additional intervention; however, chronic perforation may require otolaryngology eval-
uation. Bacterial translocation to adjacent structures may cause subsequent infection
of the labyrinth or mastoid air cells, resulting in acute labyrinthitis or acute mastoiditis,
respectively. The most severe complications are seen when there is intracranial exten-
sion of the infection. Although extremely rare, meningitis, brain abscess, and lateral
sinus thrombosis are known intracranial complications of otitis media. Any signs of
facial nerve paralysis or other focal neurologic findings in the setting of an ear infection
should be evaluated with advanced imaging, such as CT or MRI, and emergent otolar-
yngology or neurosurgery consultation.
Regarding treatment options, management of the symptoms associated with AOM
often provides patients with satisfactory relief. AOM is often painful, and otalgia should
always be treated adequately. Oral analgesics, including acetaminophen and/or
ibuprofen, are frequently recommended. Acetaminophen is additionally encouraged
for the febrile patient. Remember to use weight-based dosing for pediatric patients.
Topical intranasal vasoconstrictors, such as phenylephrine drops, may improve eusta-
chian tube function, and systemic decongestants, such as pseudoephedrine, may
also provide benefit. Narcotic pain medications are rarely needed and should be
used judiciously and only in severe cases. Topical analgesics, including antipyrine
and benzocaine otic drops, have also been suggested, but in 2015, the Food and
Drug Administration stopped the sales of ear-drop medications containing benzo-
caine and antipyrine, claiming that these medications have not been evaluated for
safety, effectiveness, and quality.8
Although the symptomatic management of AOM is largely the same for most pa-
tients, the approach to antibiotic treatments differs depending on the patient’s age.
Treatment guidelines for pediatric patients recommend a “wait-and-see” approach
in select children with nonsevere symptoms. This includes children ages 6 to
23 months with unilateral AOM, or patients 24 months and older with either unilateral
or bilateral AOM.9,10 In this population, AOM often resolves spontaneously and
without complication,11 thus avoiding the potential side effects associated with antibi-
otics and the possible proliferation of drug-resistant organisms. The "wait-and-see”
treatment option includes appropriate analgesics, joint decision making, and educa-
tion with the patient’s parents, close physician follow-up, and a plan to start antibiotics
in 48 to 72 hours if symptoms worsen or fail to improve (delayed prescription).9,10 In
children who do not qualify for the “wait-and-see” approach, the recommended
first-line treatment is amoxicillin 40 to 45 mg/kg twice a day. Treatment for 5 to

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6 Szmuilowicz & Young

7 days is suggested for children 2 years or older with nonsevere symptoms or those
who fail the “wait-and-see” period, whereas 10 days of therapy is advised for younger
patients or any patient with evidence of more severe signs or symptoms.9,10 In adult
patients, the “wait-and-see” approach to treatment has not been evaluated, and initial
treatment with antibiotics is considered the standard of practice. Similarly, amoxicillin
is also considered first-line therapy, with dosing of 500 mg every 12 hours for mild or
moderate symptoms, and 875 mg every 12 hours or 500 mg every 8 hours for more
severe cases.12 For penicillin-allergic patients, alternatives include cefdinir, cefurox-
ime, cefpodoxime, or ceftriaxone. In addition, if the patient does not seem to be
improving after 48 to 72 hours of initial therapy, alternatives include amoxicillin-
clavulanate, levofloxacin, or moxifloxacin.
Most patients will see improvement within 24 to 48 hours of starting appropriate treat-
ment. As long as there is consistent symptomatic improvement, patients may be
managed in the outpatient setting with close follow-up to assess for improvement and
treatment efficacy. If the patient is not improving, it may be appropriate to adjust the anti-
biotic regimen. Any patient that appears septic or develops complications may benefit
from inpatient admission for IV antibiotics or specialist consultation with otolaryngology.

Key points
 AOM is typically a pediatric diagnosis, but can also be seen in adults.
 AOM is diagnosed based on careful history and physical examination, including
otoscopic evaluation.
 Complications of AOM are infrequent, but should always be considered. Evi-
dence of persistent symptoms, severe infection, or abnormal focal neurologic
findings should be further evaluated with specialist consultation.
 Uncomplicated AOM in children may be treated with analgesics and the “wait-
and-see” approach to antibiotics; however, close outpatient physician follow-
up should be ensured.
 The “wait-and-see” approach has not been adequately studied in adults, and
AOM should be treated with appropriate antibiotics.

Mastoiditis
Mastoiditis generally develops as a complication of AOM when infection and inflam-
mation of the inner ear spread to the adjacent mastoid air cells. The diagnosis is
frequently made clinically, based on the history and physical examination. Patients
present with a similar constellation of symptoms than with AOM, including otalgia, fe-
ver, otorrhea, but mastoiditis is additionally classically characterized by postauricular
erythema, edema, and tenderness, with protrusion of the auricle.13 If there is any
doubt of the diagnosis, or concern for additional adjacent soft tissue involvement,
contrast CT or MRI imaging of the mastoid may be obtained. As mastoiditis is consid-
ered an invasive infection, IV antibiotics and inpatient hospital admission are generally
recommended. Early specialist consultation should also be obtained as myringotomy,
tympanostomy tube placement, and in severe cases, mastoidectomy may be
required. Antibiotic regimens should be appropriately selected to cover for the most
typically responsible pathogens, including S pneumoniae, Streptococcus pyogenes,
S aureus, and P aeruginosa.14

Key points
 Mastoiditis is a known complication of AOM due to bacterial translocation to the
mastoid air cells.

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 Infections of the Ear 7

 Patients classically present with postauricular erythema, edema, and auricular

protrusion in the setting of an AOM infection.
 CT or MRI imaging may be helpful in confirming the diagnosis or evaluating for
other possible complications.
 Management consists of IV antibiotics and otolaryngology consultation.

Myringitis
Another condition associated with otitis media is bullous myringitis. Inflammation
causes blistering and formation of bullae on the TM and the inner auditory canal. Pa-
tients typically present with severe otalgia, but can develop hearing loss or fever. As
the bullae rupture, patients can also experience otorrhea. Diagnosis is made on phys-
ical examination of the TM and ear canal with direct otoscopic visualization of the le-
sions. Bullous myringitis is caused by the typical AOM organisms; thus, management
is the same. Treatment includes oral and possibly topical analgesics and antibiotics.
Severe cases may require otolaryngology consultation for procedural rupturing of
the lesions.
Key points
 Bullous myringitis is associated with AOM and leads to blisters or bullae forming
on the TM or auditory canal secondary to inflammation.
 Bullous myringitis is associated with otorrhea, which occurs when the lesions
rupture.
 Diagnosis is made on physical examination with direct otoscopic visualization of
the lesions.
 Treatment is identical to that of the underlying AOM infection.

INNER EAR INFECTIONS

The inner ear is largely made up of 2 structures, the vestibular system and the cochlea.
The vestibular system, comprising the semicircular canals and the vestibule, is
responsible for balance, while the cochlea converts mechanical vibrations into electri-
cal signals to the brain, which makes it possible to perceive and hear sound. Although
frequently thought of as similar diseases, labyrinthitis and vestibular neuronitis are the
most common infections of the inner ear.

Labyrinthitis
As its name suggests, labyrinthitis is an infection of the labyrinth. This structure be-
comes infected by bacterial translocation into the inner ear. Most commonly, this oc-
curs secondary to AOM but has also been associated with meningitis, mastoiditis,
cholesteatoma, or after traumatic fracture of the labyrinth, which allows seeding of in-
fectious organisms. Patients typically present with some combination of vertigo,
nystagmus, or hearing loss together with evidence of an AOM infection. Patients
may also experience fever, otalgia, nausea, vomiting, or tinnitus. Although the diag-
nosis is often clinical, based on history, symptoms, and physical examination findings,
CT or MRI imaging may be useful to confirm the diagnosis or evaluate for complica-
tions. Because of the inner ear’s proximity to the central nervous system, treatment
often consists of inpatient hospital admission and IV antibiotics that provide adequate
coverage for meningitis, commonly ceftriaxone 50 to 100 mg/kg IV daily up to a
maximum of 2 g. If this diagnosis is suspected, early otolaryngologist consultation
is recommended because the patient may benefit from myringotomy or mastoidec-
tomy in more severe cases.

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8 Szmuilowicz & Young

Key points
 Labyrinthitis generally presents with vertigo and hearing loss in the setting of con-
current or recent AOM; however, it can also be associated with other infectious
or traumatic causes.
 Labyrinthitis can have severe complications due to its relative proximity to the
central nervous system.
 CT or MRI may be useful for ruling out other causes of vertigo.
 Management consists of IV antibiotics and otolaryngologist consultation.

Vestibular Neuronitis
Although often considered synonymous with labyrinthitis, vestibular neuronitis has a
few important distinctions. Patients with vestibular neuronitis present with sudden, se-
vere vertigo in the setting of an ongoing or recent upper respiratory viral infection, and
symptoms may persist for several days to a few weeks. They may additionally have
associated nausea, vomiting, and horizontal nystagmus. The diagnosis is made clin-
ically, based on history and physical examination; however, additional testing may
be needed to exclude other causes of vertigo. In contrast to labyrinthitis, these pa-
tients do not experience tinnitus or hearing loss. As it is primarily considered to be
due to a viral cause, the infection is self-limiting, and treatment consists of symptom-
atic management. In addition to traditional antiemetics, options for treatment include
medications with antiemetic properties, including anticholinergics, antihistamines, or
benzodiazepines. There is insufficient evidence to suggest improvement with cortico-
steroid medications.15
Key points
 Vestibular neuronitis is often synonymous with labyrinthitis, but is generally
thought to be associated with a viral, rather than bacterial, cause.
 Patients also present with sudden, severe vertigo, but as opposed to labyrinthitis,
do not experience tinnitus or hearing loss.
 Because the cause is ultimately due to a viral infection, management is
symptomatic.

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