Ear Infections: Otitis Media versus Otitis Externa

 

Here’s a common thread when a patient presents to  an ENT doc’s office:

     “I’m having a lot of ear infections.  That’s what those guys at the urgent care told me.”

     “What type of infections?  Did they say you have otitis media or otitis externa?”

     “No, just ‘normal’ ear infections?”

     “OK…did they mention infections of the outer ear or ear canal, or was it of the ear drum or behind the ear drum?”

     “They never said, just prescribed medications.”

      “When this happens, what do you feel in your ear?  And what kinds of medications do they use…, etc.”

And the questioning proceeds to elucidate the history to first determine the actual type of infection or if they had one at all.  Since we are mostly referral based, patients have often been treated elsewhere at an urgent care, emergency room or primary care provider’s office.  Or sometimes patients present with the self-diagnosis of “ear infections.”

Naturally, as with any medical provider, a deeper dive into history is paramount to determine the actual problem and its causes. 

I’ll ask whether they had an otitis externa or otitis media, using similar lines of questioning as above.  Sometimes outside records are not helpful.  Typically the main complaint is ear pain, but sometimes it’s a sense of ear pressure or ear plugging or ear ringing.  Oftentimes they’re in between “infections” and the ears look normal and so we must drill-down on particular symptoms to uncover what they had.  “Ear infection” is a broad definition and depends on the anatomic location.

The most common ear infections are otitis media  and otitis externa.  We’ll focus on the acute forms (short or sudden onset) these two since they are the most frequently encountered.  I’ve found discussing the distinction between the two by breaking it down to comparing symptoms, clinical findings and causes is helpful in teaching residents, medical students as well as educating patients themselves.  So I broke it down into the following tables:

Signs & symptoms	Otitis Media	Otitis Externa
Prodrome	Cold or URI (upper respiratory infection).  Travel through changing altitudes (e.g., airplane trip, travel up and down mountain passes).	Water in the ear (from bathing, swimming, hot tubbing).  Ear trauma (scratching, cleaning the ear with Qtips or other devices), ear foreign body.  Rarely impacted cerumen (ear wax)
Ear Pain	Persistent pain, usually not affected by manipulating the auricle or looking into it.	Pain often with manipulation of the auricle, or if something placed such as an otoscope
Ear Drainage	None, unless the tympanic membrane (eardrum) ruptures; then pain usually improves after	Sometimes present and does not  alleviate the pain.
Hearing Loss	Often, due to impaired sound transmission from fluid or pus n the middle ear (deep to the eardrum).	If canal is swollen enough to impair sound transmission
Tinnitus (noises in the ear)	Sometimes a pulsing (heart-beat) or throbbing sound, sometimes ear ringing.	Can hear ear ringing, usually not
Jaw problems	None	Pain to jaw, mainly TMJ (Temporal Mandibular Joint) in front of the ear.  Difficulty opening mouth or chewing, misalignment of teeth (i.e., teeth don’t meet or occlude correctly).
Neck pain	None, unless complicated by meningitis.	Sometimes with inflamed lymph nodes
Bacterial cause	Strep pneumonia, Moraxella catarrhalis, Hemophilus influenza	Pseudomonas, Staph Aureus Fungus in more chronic cases.

 

Exam Finding (during active infection)	Otitis Media	Otitis Externa
External visualization of ear	Usually none Post-auricular swelling and redness if progressed to mastoiditis.	Sometimes redness, swelling of the auricle, behind it (post-auricular) or in front of it (preauricular) or all of these.
Face	None	Sometimes swelling of the face, mainly the parotid area (from inflamed parotid nodes).
Palpation	No tenderness with auricular manipulation or inserting an ear speculum	Often tenderness with auricular manipulation or inserting an ear speculum
Otoscopic findings	Ear drum (tympanic membrane TM): bulging, red, or pus behind the TM. If spontaneous perforationàpurulent or bloody drainage in the canal.	Ear canal: redness and swelling, moisture or debris TM usually normal, sometimes red (it’s lateral surface) or cannot be seen due to canal swelling.

Treatment	Otitis Media	Otitis Externa
Antibacterial	Oral antibiotics Topical ear drops: antibiotic with or without  a steroid for TM ruptures and persistent TM perforation.	Ear drops: antibiotic with a steroid.  Sometimes oral antibiotics for infection extending to the auricle or lymph nodes of face and neck
Other	Pain medication: Tylenol or ibuprofen, analgesic ear drops	Microscopic debridement to clean the canal.  If severely swollen, placement of expandable wick with ear drops. Pain medication: Pain medication: Tylenol or ibuprofen, Keep ear dry.
Preventative	For young children: avoid bottle feeding lying down. Myringotomy and ear tubes for frequently recurring cases	Avoid water in the ear: ear plugs with bathing and swimming.  Avoid instruments or Qtips in the ear.

©Randall S. Fong, M.D.

www.randallfong.com

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