External ear problems: wax, otomycosis, furuncle, perichondritis, exostoses and keratosis obturans
- Topic
Most outer-ear problems are wax, infection or bony growths; each has a clue on otoscopy and a simple first treatment.
What it is
The outer ear runs from the pinna to the eardrum. Its outer third is cartilage with hair, sebaceous and ceruminous glands; its inner two thirds is thin skin on bone with no glands. That anatomy explains the diseases: wax and furuncles in the outer part, exostoses in the bony part, and painful infections because the skin sits tight on cartilage and bone. This page groups the external ear problems that are not covered by the diffuse otitis externa and necrotising otitis externa pages: wax impaction, fungal otitis externa (otomycosis), furunculosis, perichondritis of the pinna, bullous myringitis, exostoses and osteoma, and keratosis obturans with its look-alike, ear canal cholesteatoma.
Key facts
- Wax clears itself by migration of canal skin; cotton buds push it in. Risk factors for impaction: hearing aids, earplugs, older age, cognitive impairment and narrow or bony canals.
- Wax removal: softening drops (water-based or oil-based), then irrigation with water at body temperature, or manual removal with a curette, hook or suction under direct vision.
- Otomycosis: the canal looks like wet blotting paper with spores; pain is less than in bacterial otitis externa; recurrence is common; check for diabetes when it keeps returning.
- Furuncle: may point and drain; differential with mastoiditis: in a furuncle the postauricular groove is preserved and moving the pinna hurts.
- Perichondritis may follow surgery, burns, trauma or a neglected haematoma; delay leads to cartilage necrosis and a «cauliflower ear». Bilateral recurrent pinna inflammation suggests relapsing polychondritis.
- Bullous myringitis: painful blood-filled or clear blisters on the eardrum, usually viral; if the middle ear is involved it is treated as acute otitis media.
- Keratosis obturans is linked to bronchiectasis and chronic sinusitis; treatment is removal of the keratin plug (often under the microscope) and regular cleaning.
Structure
- Wax and debris: cerumen impaction, foreign bodies (see their own page), keratosis obturans.
- Infection: diffuse otitis externa, otomycosis, furunculosis, bullous myringitis, herpes zoster oticus, necrotising otitis externa.
- Pinna: perichondritis, auricular haematoma, keloid of the lobule after piercing, relapsing polychondritis.
- Bony growths: exostoses and osteoma.
- Erosive and neoplastic: ear canal cholesteatoma and carcinoma (see the ear tumours page).
External ear: the clue and the first step
| Condition | Key clue | First management |
|---|---|---|
| Wax impaction | Hearing loss, fullness; wax hides the eardrum | Softening drops, irrigation or manual removal |
| Otomycosis | Itching; black or white fluffy debris | Aural cleaning and topical antifungal (clotrimazole) or acidifying drops |
| Furuncle | Painful red swelling in the outer canal; pain on chewing | Analgesia, warm compresses, oral anti-staphylococcal antibiotic; drain if it points |
| Diffuse otitis externa | Swollen canal, pain on pulling the pinna | Cleaning, antibiotic ± steroid drops, wick if swollen |
| Perichondritis | Red, tender pinna sparing the lobule | Antipseudomonal antibiotic (fluoroquinolone); drain abscess; urgent ENT |
| Bullous myringitis | Severe pain, blisters on the eardrum | Analgesia; treat as otitis media if the middle ear is involved |
| Exostoses or osteoma | Hard, skin-covered bony swellings | Observe; canalplasty if they trap wax and water |
| Keratosis obturans | Bilateral, painful, wide canal with laminated keratin | Removal under the microscope and regular cleaning |
| Ear canal cholesteatoma | One side, otorrhoea, bone erosion of the canal floor | CT and ENT surgery |
In clinical practice
- Diabetic or immunocompromised patient with severe night pain and granulation in the canal floor: necrotising otitis externa until proven otherwise.
- Facial weakness with ear pain and vesicles: Ramsay Hunt syndrome.
- Granulation or bleeding in the canal that does not heal, or pain out of proportion: biopsy to exclude carcinoma.
- Pinna inflammation after piercing through cartilage: start antipseudomonal cover early to save the cartilage.
Next step / Initial management
- First workup: otoscopy after gentle cleaning; swab for culture when discharge persists or recurs; check blood glucose in recurrent or severe infection.
- First-line management: aural cleaning, topical drops chosen by cause (quinolone ± steroid for bacterial, clotrimazole or acidifying drops for fungal), analgesia; avoid aminoglycoside drops if the eardrum may be perforated.
- Routine referral to ENT: wax that cannot be removed, exostoses that cause recurrent infection, keratosis obturans, otomycosis that keeps returning.
- Urgent (same-day or within 24 hours) referral to ENT: perichondritis or pinna abscess, suspected necrotising otitis externa, cranial nerve palsy, or a non-healing canal lesion suggesting cancer (urgent cancer pathway).
Test yourself
Think of the answer, then tap the question to see it.
After two weeks of antibiotic ear drops, a swimmer has intense itching and black specks on wet white debris in the canal. Diagnosis and treatment?
Otomycosis (Aspergillus niger): careful aural cleaning plus a topical antifungal such as clotrimazole, stopping the antibiotic drops.
Two days after a helix piercing, the upper pinna is red, hot and swollen while the lobule is normal. Which organism and which drug class?
Perichondritis, usually Pseudomonas aeruginosa: an antipseudomonal antibiotic such as a fluoroquinolone, drainage of any abscess and urgent ENT review.
A surfer has bilateral, broad-based, hard swellings in the deep part of both ear canals. What are they?
Exostoses of the bony ear canal, linked to repeated cold-water exposure; observe, and consider canalplasty if they trap wax or water.
A 20-year-old with bronchiectasis has severe bilateral ear pain, conductive hearing loss and a laminated keratin plug in widened canals. Diagnosis?
Keratosis obturans: remove the plug under the microscope and arrange regular cleaning.
Connections
In Pharmacology3
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Cerumen Impaction Removal (StatPearls Publishing (NCBI Bookshelf), 2023); Ear Irrigation (StatPearls Publishing (NCBI Bookshelf), 2026); Otitis Externa (StatPearls Publishing (NCBI Bookshelf), 2023); Pinna Perichondritis (StatPearls Publishing (NCBI Bookshelf), 2024); Bullous Myringitis (StatPearls Publishing (NCBI Bookshelf), 2023); Necrotizing (Malignant) Otitis Externa (StatPearls Publishing (NCBI Bookshelf), 2023); Otomycosis: diagnosis and treatment (Clin Dermatol) (Clinics in Dermatology (PubMed), 2010); Contemporary management of keratosis obturans: a systematic review (J Laryngol Otol) (The Journal of Laryngology & Otology (PubMed), 2021).
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Representative model, for educational purposes only.