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Otitis Externa

Otitis externa

Definition

Otitis externa refers to an infection of the ear canal (outer ear), the tube leading from the outside opening of the ear in towards the ear drum. The infection usually develops in children and adolescents whose ears are exposed to persistent, excessive moisture.

Description

The external ear canal is a tube approximately 1 in (2.5 cm) in length that runs from the outside opening of the ear to the start of the middle ear, which is behind the tympanic membrane (ear drum). The canal is partly cartilage and partly bone. The lining of the ear canal is skin, which is attached directly to the covering of the bone. Glands within the skin of the canal produce a waxy substance called cerumen (popularly called earwax). Cerumen is designed to protect the ear canal, repel water, and keep the ear canal too acidic to allow bacteria to grow.

Continually exposing the ear canal to moisture may cause significant loss of cerumen. The delicate skin of the ear canal, unprotected by cerumen, retains moisture and becomes irritated. Without cerumen, the ear canal stops being appropriately acidic, which allows for the growth of microorganisms. Thus, the warm, moist, dark environment of the ear canal becomes a hospitable environment for development of an infection.

Otitis externa is commonly referred to as swimmer's ear.

Demographics

Although all age groups are affected by otitis externa, children, adolescents, and young adults whose ears are exposed to persistent, excessive moisture develop the infection most often. Otitis externa occurs most often in warm climates and during the summer months, when more people are participating in water activities. The ratio of occurrence in males is equal to that of females. People in some racial groups have a smaller size of the ear canal, which may predispose them to infection.

Causes and symptoms

Chidren and adolescents with otitis externa often have been diving or swimming for long periods of time, especially in polluted lakes, rivers, or ponds. Routine showering can also lead to otitis externa. Water in the ear canal can carry infectious microorganisms into the ear canal.

Bacteria, fungi, and viruses have all been implicated in causing otitis externa. However, most commonly otitis externa is caused by bacteria, especially Pseudomonas aeruginosa. Other bacteria that can cause otitis externa include Enterobacter aerogenes, Proteus mirabilis, Klebsiella pneumoniae, Staphylococcus epidermidis, and bacteria of the family called Streptococci. Occasionally, fungi may cause otitis externa. These include Candida and Aspergillus. Two types of viruses, called herpesvirus hominis and varicella-zoster virus, have also been identified as causing otitis externa.

Other conditions predisposing to otitis externa include the use of cotton swabs to clean the ear canals. This pushes cerumen and normal skin debris back into the ear canal, instead of allowing the ear canal's normal cleaning mechanism of the ear to work, which would ordinarily move accumulations of cerumen and debris out of the ear. Also, putting other items into the ear can scratch the canal, making it more susceptible to infection. For example, children may insert a foreign body in their ear canal and not mention it to their parents. Hair spray or hair coloring, which can irritate the ear canal, may also lead to otitis externa. A hearing aid can trap moisture in the ear canal and should be taken out as often as possible to allow the ear an opportunity to dry out.

The first symptom of otitis externa is often itching of the ear canal, followed by watery discharge from the ear. Eventually, the ear begins to feel extremely painful. Any touch, movement, or pressure on the outside structure of the ear may cause severe pain . If the canal is excessively swollen, hearing may become muffled. The canal may appear swollen and red, and there may be evidence of foul-smelling, greenish-yellow pus.

In severe cases, otitis externa may be accompanied by fever . Often, this indicates that the outside ear structure has become infected as well. It will become red and swollen, and there may be enlarged and tender lymph nodes in front of, or behind, the ear.

A serious and life-threatening type of otitis externa is called malignant otitis externa. This is an infection that most commonly affects persons who have diabetes or in persons with weakened immune systems. In malignant otitis externa, a patient has usually had minor symptoms of otitis externa for some months, with pain and drainage. The causative bacteria is usually Pseudomonas aeruginosa. This bacteria spreads from the external canal into all of the nearby tissues, including the bones of the skull. Swelling and destruction of these tissues may lead to damage of certain nerves, resulting in spasms of the jaw muscles or paralysis of the facial muscles. Other, more severe, complications of this destructive infection include meningitis (swelling and infection of the coverings of the spinal cord and brain), brain infection, or brain abscess (the development of a pocket of infection with pus).

When to call the doctor

The doctor should be called if any of the following symptoms are present:

  • pain in an ear with or without fever
  • persistent itching of the ear or in the ear canal
  • loss of hearing or decreased hearing in one or both ears
  • discharge from an ear, especially if it is thick, discolored, bloody, or foul-smelling

Diagnosis

Diagnosis of uncomplicated otitis externa is usually quite simple. The symptoms alone, of ear pain worsened by any touch to the outer ear, are characteristic of otitis externa. Examination of the ear canal will usually reveal redness and swelling. It may be impossible (due to pain and swelling) to see much of the ear canal, but this inability itself is diagnostic.

If there is a need to identify the types of organisms causing otitis externa, the canal can be gently swabbed to obtain a specimen. The organisms present in the specimen can then be cultured (allowed to multiply) in a laboratory, and then viewed under a microscope to allow identification of the causative organisms.

If the rare infection malignant otitis externa is suspected, computed tomography scan (CT scan) or magnetic resonance imaging (MRI) scans will be performed to determine how widely the infection has spread within bone and tissue. A swab of the external canal will not necessarily reveal the actual causative organism, so some other tissue sample (biopsy) will need to be obtained. The CT or MRI will help the doctor decide where the most severe focus of infection is located, in order to guide the choice of a biopsy site.

Treatment

Otitis externa us usually not a dangerous condition and often clears up by itself within a few days. To aid in the healing, the infected ear canal can be washed with an over-the-counter topical antiseptic. Pain can be relieved be placing a warm heating pad or compress on the infected ear as well as through the use of an over-thecounter pain reliever such as acetaminophen or aspirin. During the healing process, the infected ear canal must be kept dry, even while showering, through the use of ear plugs or a shower cap.

If the pain worsens or does not improve within 24 hours, or for the fastest way to relieve pain and to prevent the spread of infection, the doctor should be seen. The doctor will clean the ear with a suction-tipped probe or other type of suction device to relieve irritation and pain. Antibiotics will applied directly to the skin of the ear canal (topical antibiotics ) to fight the infection. These antibiotics are often combined in a preparation that includes a steroid medication that reduces the itching, inflammation and swelling within the ear canal. For full treatment, eardrops are usually applied several times a day for seven to 10 days.

If the opening to the ear is narrowed by swelling, a cotton wick may be inserted into the ear canal to help carry the eardrops into the ear more effectively. The medications are applied directly to the wick, enough times per day to allow the wick to remain continuously saturated. After the wick is removed, usually after about 48 hours, the medications are then put directly into the ear canal three to four times each day.

For severe infection, oral antiobiotics may be prescribed. If the otitis externa infection is caused by the presence of a foreign body in the ear, the infection will not improve until the foreign body is removed.

In malignant otitis externa, antibiotics will almost always need to be given intravenously (IV). If the CT or MRI scan reveals that the infection has spread extensively, these IV antibiotics will need to be continued for six to eight weeks. If the infection is in an earlier stage, two weeks of IV antibiotics can be followed by six weeks of antibiotics by mouth.

Alternative treatment

Mullein (Verbascum thapsus ) oil has anti-inflammatory properties and may be apppied to the infected ear canal (one to three drops every three hours) to help soothe and heal the ear. Garlic (Allium sativum ) is a natural antibiotic. Garlic juice can be combined with equal parts of glycerin and a carrier oil such as olive or sweet olive and applied (one to three drops) to the infected ear every three hours.

Prognosis

The prognosis is excellent for otitis externa, for it is usually easily treated. Basic treatment measures will cure 90 percent of cases without complication. However, it may recur in certain susceptible individuals. Left untreated, malignant otitis externa may spread sufficiently to cause death.

Prevention

Swimming in polluted water and in pools or hot tubs without good chlorine and pH control should be avoided.

Keeping the ear dry is an important aspect of prevention of otitis externa. Before swimming, a protective coating consisting of several drops of mineral oil, baby oil, or lanolin can be applied to the ear canal. After swimming, several drops of a mixture of isopropyl alcohol and white vinegar can be put into the ear canal to ensure that it dries adequately. The head should be tilted so that the solution reaches the bottom of the ear canal; then the liquid should be drained out.

Care should be taken when cleaning ears. The outer ear should be cleaned wiped with a clean washcloth. The use of pointed objects to dig into the ear canal, especially those that can scratch the skin, should be avoided.

The most serious complications of malignant otitis externa can be avoided by careful attention to early symptoms of ear pain and drainage from the ear canal. Children with conditions that put them at higher risk for this infection (diabetes or conditions that weaken the immune system) should always report new symptoms immediately to the doctor.

KEY TERMS

Cerumen The medical term for earwax.

Eardrum A paper-thin covering stretching across the ear canal that separates the middle and outer ears.

Infectious disease A disease caused by a virus or a bacterium. Examples of viruses causing an infectious disease are: HIV-1 virus, herpes simplex, cytomegalovirus, Epstein-Barr virus, leukemia virus. Examples of bacterial infectious diseases are: syphilis and tuberculosis.

Outer ear Outer visible portion of the ear that collects and directs sound waves toward the tympanic membrane by way of a canal which extends inward through the temporal bone.

Parental concerns

Parents should teach their children how to clean their ears without using sharp objects and to dry their ears thoroughly after swimming, showering, or bathing.

Resources

BOOKS

"External Otitis." In Nelson Textbook of Pediatrics, ed. Richard E. Behrman. Philadelphia: W. B. Saunders Co., 1996.

Friedman, Ellen M. My Ear Hurts! Fireside, 2001.

PERIODICALS

"Keep Your Ears Dry." Consumer Reports on Health, 7, no. 7 (July 1995): 80+.

Moss, Richard. "Swimmers Ear." Pediatrics for Parents 17, no. 4 (Apr. 1996): 3+.

ORGANIZATIONS

American Academy of Otolaryngology-Head and Neck Surgery, Inc. One Prince St., Alexandria VA 22314-3357. (703) 836-4444. Web site:<http://www.entnet>.

WEB SITES

"Healthy Swimming." National Center for Infectious Diseases, Centers for Disease Control and Prevention. <cdc.gov/healthyswimming/swimmers_ear.htm>.

Judith Sims

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Swimmer's Ear

Swimmer's ear

Definition

Swimmer's ear, also known as otitis externa, is an inflammation of the outer ear canal. Although it is most prevalent among young adults and children, who often contract the condition from frequent swimming, swimmer's ear can affect anyone.

Description

Swimmer's ear is an inflammation of the outer ear that may lead to a painful and often itchy infection. It begins with the accumulation of excess moisture from swimming or daily showering. The skin inside the ear canal may flake due to moisture. This flaking may cause persistent itching that may lead to a break in the skin from scratching. Broken skin allows bacteria or a fungus to infect the tissues lining the ear canal. Swimming in polluted water can easily bring harmful bacteria into the outer ear.

Causes & symptoms

Causes

In swimmer's ear, the patient nearly always has a history of recent exposure to water combined with mild injury to the skin of the inner ear. This injury is typically caused by scratching or excessive and improper attempts to clean wax from the ears. Wax is one of the best defense mechanisms the ear has against infection due to the protection it offers from excess moisture and the environment it provides for friendly bacteria. Earwax should not be removed by such sharp objects as fingernails or hairpins. If the wax is scratched away, it becomes easier for an infection to occur.

The infection itself is usually caused by gram-negative bacilli (Pseudomonas aeruginosa or Proteus ) or by fungi (Aspergillus ) or even yeasts that thrive in moist environments. There are a surprisingly large number of different organisms that can cause otitis externa; one study of 2039 patients diagnosed with swimmer's ear found that 202 different species of bacteria, 32 species of yeast, and 17 species of mold could be identified as the infectious agents in this group of patients.

In recent years, some of the organisms most likely to cause otitis externa have developed resistance to antibiotics; the resistant organisms vary from country to country. One Asian study found that Staphylococcus aureus is responsible for more cases of swimmer's ear in East Asia than Pseudomonas aeruginosa, and that methicillin-resistant S. aureus, or MRSA, is an increasingly worrisome problem in these countries. A study done in Texas, however, found that Staphylococcus epidermidis was responsible for the largest number of antibiotic-resistant cases.

In a minority of cases, otitis externa is caused by an allergic reaction. The most common allergens in chronic otitis externa are topical medications used in the ear, particularly preparations containing neomycin; nickel and other metals used in inexpensive earrings; and some materials used to make hearing aids.

Symptoms

The symptoms of swimmer's ear include swelling, redness, heat, and pain . The inflammation may produce a foul-smelling, yellowish, or watery discharge from the ear. The skin inside the ear canal may swell to the point that the examiner cannot see the patient's eardrum.

The patient may also experience itching inside the ear and a temporary minor hearing loss due to the blockage of the ear canal. The severe pain and tenderness associated with the condition may intensify when the patient's head is moved, or if the examiner gently pulls the earlobe.

Diagnosis

The diagnosis of swimmer's ear is made from clinical observation. The doctor looks inside the ear with an instrument called an otoscope. The otoscope allows him or her to see whether there is swelling, redness, and a discharge. The doctor may also take a specimen of the discharge by swabbing just inside the ear. This specimen is then sent to a laboratory to identify the bacterium or fungus.

Treatment

Swimmer's ear is not usually a dangerous infection and often heals itself within a few days. If the infection is mild, alternative methods of treatment may be beneficial.

Herbal remedies

Native Americans used mullein (Verbascum thapsus ) oil to treat minor inflammations. To ease the discomfort of swimmer's ear, 13 drops of a mullein preparation may be placed in the ear every three hours.

Garlic (Allium sativum ) has been shown to be effective in treating swimmer's ear. As a natural antibiotic, garlic is a useful herb for inflammation of the outer ear. Equal parts of garlic juice and glycerin are added to a carrier oil, such as olive or sweet almond. One to three drops of this mixture may be placed in the infected ear every three hours.

Homeopathy

Specific homeopathic remedies for swimmer's ear may include Aconite, Apis, Graphites, or Pulsatilla. A homeopathic practitioner should always be consulted for specific treatment recommendations.

A 1997 German study found that homeopathic treatments reduced the duration of pain in children with ear infections more quickly than those treated with conventional drugs. The homeopathic-treated group was also found to have a greater resistance to recurrence of the infection within one year after treatment.

Home remedies

The inflammation and pain of otitis externa may be eased with the following home remedies:

  • The infected ear canal may be washed with an over-the-counter topical antiseptic. A homemade solution using equal parts white vinegar and isopropyl alcohol may be placed, a few drops at a time, into the ear every two to three hours. The vinegar-alcohol drops should be kept in the ear for at least 30 seconds.
  • A warm heating pad or compress may be placed on the ear to relieve pain.
  • Pain may also be eased by taking aspirin or another analgesic.
  • To assist the healing process, the infected ear canal should be kept dry. When showering, the patient should use earplugs or a shower cap.

Allopathic treatment

A doctor will use conventional medicine to treat swimmer's ear. The ear is typically cleaned with a cotton-tipped probe or a suction device to relieve irritation and pain. Ear drops containing a combination of hydrocortisone to help relieve the itching and an antibiotic to fight infection (usually neomycin sulfate and polymyxin B sulfate) may be prescribed.

For severe pain, doctors may recommend aspirin, acetaminophen, or some other over-the-counter pain medication. To assist the healing process, the infected ear must be kept dry. An infection typically begins to improve within three to four days. If the pain persists or becomes worse, the doctor may prescribe an oral antibiotic or an anti-inflammatory drug.

If the doctor prescribes an oral antibiotic to treat the infection, it is important for the patient to finish taking the entire course of medication even if he or she feels better fairly quickly. The reason is that a single antibiotic can kill off most of the bacteria causing the infection, but a few organisms may survive that have a higher degree of natural resistance to the drug. If the patient stops taking the antibiotic too soon, not all the bacteria will be killed off, and those that survive may develop resistance to the particular drug that was used.

If the otitis externa is caused by an allergic reaction, a patch test is necessary in order to identify the substance or object that is causing the reaction. Treatment consists of avoiding further contact with the allergen; or switching medications if the patient has developed an allergic sensitivity to a topical ear medication.

Expected results

Swimmer's ear is usually a minor inflammation of the outer ear canal that may even heal itself within a few days. It usually responds to many alternative treatments as well as to the conventional methods prescribed by doctors.

Rapidly spreading redness and swelling of the outer ear or nearby skin, or fever , are indications of an aggressively spreading infection. These symptoms require immediate medical attention.

Prevention

Prevention is the key component in avoiding swimmer's ear. Patients should be careful when cleaning the earsnever dig into the ear canal; wear earplugs when swimming and avoid swimming in dirty water; and use earplugs or a shower cap when showering.

Additional methods to ensure the prevention of swimmer's ear include: putting a dropperful of isopropyl alcohol or white vinegar into the ear after swimming or showering to dry out the ear and help kill germs; before swimming, create a protective coating by squirting a dropperful of mineral oil, baby oil, or lanolin into the ear; and when wearing a hearing aid, remove it often to allow the ear an opportunity to dry out completely.

Resources

BOOKS

Cummings, Stephen, MD, and Dana Ullman, MPH. Everybody's Guide to Homeopathic Medicines. New York: G. P. Putnam's Sons, 1991.

The Editors of Time-Life Books. The Medical Advisor: The Complete Guide to Alternative & Conventional Treatments. Richmond, VA: Time-Life Inc., 1996.

The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

PERIODICALS

Berenholz, L., U. Katzenell, and M. Harell. "Evolving Resistant Pseudomonas to Ciprofloxacin in Malignant Otitis Externa." Laryngoscope 112 (September 2002): 1619-1622.

Hwang, J. H., C. K. Chu, and T. C. Liu. "Changes in Bacteriology of Discharging Ears." Journal of Laryngology and Otology 116 (September 2002): 686-689.

Ramsey, A. M. "Diagnosis and Treatment of the Child with a Draining Ear." Journal of Pediatric Health Care 16 (July-August 2002): 161-169.

Roland, P. S., and D. W. Stroman. "Microbiology of Acute Otitis Externa." Laryngoscope 112 (July 2002): 1166-1177.

Sood, S., D. R. Strachan, A. Tsikoudas, and G. I. Stables. "Allergic Otitis Externa." Clinical Otolaryngology 27 (August 2002): 233-236.

ORGANIZATIONS

American Academy of Otolaryngology-Head and Neck Surgery. 1 Prince Street. Alexandria, VA 22314. (703) 836-4444.

American Academy of Pediatrics (AAP). 141 Northwest Point Boulevard, Elk Grove Village, IL 60007. (847) 434-4000. <www.aap.org>.

International Foundation for Homeopathy. 2366 Eastlake Avenue East, Suite 329. Seattle, WA 98102. (206) 324-8230.

Beth Kapes

Rebecca J. Frey, PhD

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Otitis Externa

Otitis Externa

Definition

Otitis externa refers to an infection of the ear canal, the tube leading from the outside opening of the ear in towards the ear drum.

Description

The external ear canal is a tube approximately 1 in (2.5 cm) in length. It runs from the outside opening of the ear to the start of the middle ear, designated by the ear drum or tympanic membrane. The canal is partly cartilage and partly bone. In early childhood, the first two-thirds of the canal is made of cartilage, and the last one-third is made of bone. By late childhood, and lasting throughout all of adulthood, this proportion is reversed, so that the first one-third is cartilage, and the last two-thirds is bone. The lining of the ear canal is skin, which is attached directly to the covering of the bone. Glands within the skin of the canal produce a waxy substance called cerumen (popularly called earwax). Cerumen is designed to protect the ear canal, repel water, and keep the ear canal too acidic to allow bacteria to grow.

Causes and symptoms

Bacteria, fungi, and viruses have all been implicated in causing ear infections called otitis externa. The most common cause of otitis externa is bacterial infection. The usual offenders include Pseudomonas aeruginosa, Enterobacter aerogenes, Proteus mirabilis, Klebsiella pneumoniae, Staphylococcus epidermidis, and bacteria of the family called Streptococci. Occasionally, fungi may cause otitis externa. These include Candida and Aspergillus. Two types of viruses, called herpesvirus hominis and varicella-zoster virus, have also been identified as causing otitis externa.

Otitis externa occurs most often in the summer months, when people are frequenting swimming pools and lakes. Continually exposing the ear canal to moisture may cause significant loss of cerumen. The delicate skin of the ear canal, unprotected by cerumen, retains moisture and becomes irritated. Without cerumen, the ear canal stops being appropriately acidic, which allows bacteria the opportunity to multiply. Thus, the warm, moist, dark environment of the ear canal becomes a breeding ground for bacteria.

Other conditions predisposing to otitis externa include the use of cotton swabs to clean the ear canals. This pushes cerumen and normal skin debris back into the ear canal, instead of allowing the ear canal's normal cleaning mechanism to work, which would ordinarily move accumulations of cerumen and debris out of the ear. Also, putting other items into the ear can scratch the canal, making it more susceptible to infection.

The first symptom of otitis externa is often itching of the ear canal. Eventually, the ear begins to feel extremely painful. Any touch, movement, or pressure on the outside structure of the ear (auricle) may cause quite severe pain. This is because of the way in which the skin lining the ear canal is directly attached to the covering of the underlying bone. If the canal is sufficiently swollen, hearing may become muffled. The canal may appear swollen and red, and there may be evidence of greenish-yellow pus.

In severe cases, otitis externa may have an accompanying fever. Often, this indicates that the outside ear structure (auricle) has become infected as well. It will become red and swollen, and there may be enlarged and tender lymph nodes in front of, or behind, the auricle.

A serious and life-threatening otitis externa is called malignant otitis externa. This is an infection which most commonly affects patients who have diabetes, especially the elderly. It can also occur in other patients who have weakened immune systems. In malignant otitis externa, a patient has usually had minor symptoms of otitis externa for some months, with pain and drainage. The causative bacteria is usually Pseudomonas aeruginosa. In malignant otitis externa, this bacteria spreads from the external canal into all of the nearby tissues, including the bones of the skull. Swelling and destruction of these tissues may lead to damage of certain nerves, resulting in spasms of the jaw muscles or paralysis of the facial muscles. Other, more severe, complications of this very destructive infection include meningitis (swelling and infection of the coverings of the spinal cord and brain), brain infection, or brain abscess (the development of a pocket of infection with pus).

Diagnosis

Diagnosis of uncomplicated otitis externa is usually quite simple. The symptoms alone, of ear pain worsened by any touch to the auricle, are characteristic of otitis externa. Attempts to examine the ear canal will usually reveal redness and swelling. It may be impossible (due to pain and swelling) to see much of the ear canal, but this inability itself is diagnostic.

If there is any confusion about the types of organisms causing otitis externa, the canal can be gently swabbed to obtain a specimen. The organisms present in the specimen can then be cultured (allowed to multiply) in a laboratory, and then viewed under a microscope to allow identification of the causative organisms.

If the rare disease malignant otitis externa is suspected, computed tomography scan (CT scan) or magnetic resonance imaging (MRI) scans will be performed to determine how widely the infection has spread within bone and tissue. A swab of the external canal will not necessarily reveal the actual causative organism, so some other tissue sample (biopsy) will need to be obtained. The CT or MRI will help the practitioner decide where the most severe focus of infection is located, in order to guide the choice of a biopsy site.

Treatment

Antibiotics which can be applied directly to the skin of the ear canal (topical antibiotics ) are usually excellent for treatment of otitis externa. These are often combined in a preparation which includes a steroid medication. The steroid helps cut down on the inflammation and swelling within the ear canal. Some practitioners prefer to insert a cotton wick into the ear canal, leaving it there for about 48 hours. The medications are applied directly to the wick, enough times per day to allow the wick to remain continuously saturated. After the wick is removed, the medications are then put directly into the ear canal three to four times each day.

In malignant otitis externa, antibiotics will almost always need to be given through a needle in the vein (intravenously or IV). If the CT or MRI scan reveals that the infection has spread extensively, these IV antibiotics will need to be continued for six to eight weeks. If the infection is in an earlier stage, two weeks of IV antibiotics can be followed by six weeks of antibiotics by mouth.

Prognosis

The prognosis is excellent for otitis externa. It is usually easily treated, although it may tend to recur in certain susceptible individuals. Left untreated, malignant otitis externa may spread sufficiently to cause death.

Prevention

Keeping the ear dry is an important aspect of prevention of otitis externa. Several drops of a mixture of alcohol and acetic acid can be put into the ear canal after swimming to insure that it dries adequately.

The most serious complications of malignant otitis externa can be avoided by careful attention to early symptoms of ear pain and drainage from the ear canal. Patients with conditions that put them at higher risk for this infection (diabetes, conditions which weakened the immune system) should always report new symptoms immediately.

Resources

ORGANIZATIONS

American Academy of Otolaryngology-Head and Neck Surgery, Inc. One Prince St., Alexandria VA 22314-3357. (703) 836-4444. http://www.entnet.org.

KEY TERMS

Auricle The external structure of the ear.

Biopsy The removal and examination, usually under a microscope, of tissue from the living body. Used for diagnosis.

Cerumen Earwax.

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"Otitis Externa." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved April 28, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/otitis-externa