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Examination includes the ear canal, tympanic membrane, the auricle, and cervical nodes, as well as a cutaneous survey for other dermatologic manifestations.

Cerumen or debris that blocks the canal is cleared to verify tympanic integrity.

Disease can range from mild inflammation, which occurs in approximately 50 percent of cases, to life-threatening temporal bone infections in less than 0.5 percent.26 Chronic OE is characterized by pruritus, mild discomfort, and an erythematous external canal that may or may not be lichenified.

For both types, treatment includes topical therapy and amelioration of inciting factors.

Less than 5 percent of acute disease cases can be attributed to furunculosis (usually staphylococcal), herpes zoster oticus, or nonspecific conditions (e.g., bullous myringitis).215 A common cause of chronic OE is allergic contact dermatitis from such things as metal earrings, chemicals in cosmetics or shampoos, or the plastic in hearing aids or protection devices.

Generalized skin conditions such as atopic dermatitis (i.e., eczema) or psoriasis can be difficult to treat in the narrow ear canal.

The chronic form is commonly of a fungal or allergic origin or is the manifestation of dermatitides.

It affects 3 to 5 percent of the population.14 Acute OE is unilateral in 90 percent of patients; it peaks in persons seven to 12 years of age, declines after 50 years of age, and often is associated with high humidity, warmer temperatures, swimming, local trauma, and hearing aid or hearing protector use.5Manifestations include pruritus, pain, and erythema, but as the disease progresses, other problems such as edema, otorrhea, and conductive hearing loss may develop.

Cerumen in acute OE tends to be hydrated by the otorrhea, making it easier to remove.

If left untreated, acute disease can be followed by canal edema, discharge, and pain, and eventually by extra-canal manifestations.

Topical application of an acidifying solution is usually adequate in treating early disease.

Evaluation includes taking a history of the onset and nature of symptoms; and of prior issues with skin disorders or local trauma, particularly via cotton swab or bobby pin.

Patients with diabetes, those who are immunocompromised, and those with local circulatory insufficiency (e.g., from irradiation) are prone to rapid escalation from mild to severe manifestations.3 Regardless of the ototopical selected, penetration to the epithelium is mandatory; any obstruction should be cleared.

Although this is adequate therapy in most patients, at least 25 percent will be given an oral antibiotic.4Add oral antibiotic if there is severe disease in an immunocompetent patient or if there is moderate or severe disease in those who are immunocompromised, who have diabetes or advanced age, and in patients with concomitant otitis media.

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