What are the symptoms of otitis externa?

Symptoms of Otitis Externa

The hallmark symptoms of acute otitis externa are ear pain (otalgia) that is characteristically intense and disproportionate to visible findings, along with tenderness when the tragus is pushed or the pinna is pulled, which distinguishes it from middle ear disease. 1

Cardinal Symptoms

• Otalgia (ear pain) occurs in approximately 70% of patients and is the most prominent symptom, often described as severe and out of proportion to the physical examination findings 1
• Tenderness with manipulation of the tragus (when pushed) or pinna (when pulled) is pathognomonic for otitis externa and helps differentiate it from acute otitis media, where such manipulation does not typically worsen pain 1, 2
• Itching (pruritus) is present in approximately 60% of patients and may precede other symptoms 1
• Ear fullness occurs in about 22% of cases 1

Additional Clinical Manifestations

• Hearing loss develops in approximately 32% of patients, typically due to canal edema or debris obstructing sound transmission 1
• Otorrhea (ear discharge) may be present and can be variable in character—clear, purulent, or bloody depending on the severity and causative organism 1, 3
• Pain with chewing can occur due to movement of the temporomandibular joint affecting the inflamed ear canal 1

Physical Examination Findings

• Diffuse ear canal edema and erythema are visible on otoscopy, with or without debris or discharge in the canal 1
• Regional lymphadenitis or cellulitis of the pinna and adjacent skin may be present in more severe cases 1
• Normal tympanic membrane mobility on pneumatic otoscopy distinguishes otitis externa from otitis media, which shows limited or absent mobility 1, 2

Variant Presentations Requiring Recognition

Fungal Otitis Externa (Otomycosis)

• Intense pruritus is more prominent than pain 1
• Thickened otorrhea that may be black, gray, bluish-green, yellow, or white depending on the fungal species 1
• White debris with sprouting hyphae (Candida) or appearance of "wet newspaper" with black dots (Aspergillus niger) 1

Necrotizing (Malignant) Otitis Externa

• Severe, unrelenting pain that is refractory to typical analgesics 4
• Granulation tissue classically visible on the floor of the canal at the bony-cartilaginous junction 1
• Facial nerve paralysis may be an early sign of this life-threatening condition 1
• Occurs primarily in elderly diabetic or immunocompromised patients 4

Localized Otitis Externa (Furunculosis)

• Focal swelling and pustular lesions rather than diffuse canal involvement 4
• Localized tenderness over the affected hair follicle in the outer third of the canal 4

Common Pitfall

Otitis externa can mimic acute otitis media because erythema may involve the tympanic membrane, but pneumatic otoscopy will demonstrate good tympanic membrane mobility with otitis externa versus absent or limited mobility with otitis media. 1, 2 This distinction is critical because it determines whether topical therapy alone (otitis externa) or systemic antibiotics (otitis media) are required.