REVIEW

Allergic otitis externa

S. SOOD,

D. R. STRACHAN,

A. TSIKOUDAS

& G. I. STABLESy

Department of OtolaryngologyHead & Neck Surgery, Bradford Royal Inrmary, Bradford, and yDepartment of
Dermatology, Pinderelds Hospital, Wakeeld, UK
Accepted for publication 7 January 2002
SOOD S. , STRACHAN D. R. , TSI KOUDAS A. & STABLES G. I .
(2002) Clin. Otolaryngol. 27, 233236
Allergic otitis externa
Chronic otitis externa is a common condition, which is usually successfully treated by topical medications
and aural toilet. In cases that persist despite conventional treatment, a diagnosis of allergic otitis externa
should be considered. Sensitization to otic medications (secondary contact otitis) is not uncommon. Topical
aminoglycosides are the most common sensitizers although many components of topical preparations can cause
sensitization. Patients who may have developed allergic otitis externa should undergo patch testing.
Otolaryngologists should consider using topical antibiotics with a lowallergenic potential and avoiding neomycin
when treating patients with otitis externa. Primary contact otitis may occur to metals used in earrings and also
to hearing aid moulds. Treatment of both primary and secondary contact otitis consists of identifying the
allergen, avoiding further contact and use of simple preparations avoiding common sensitizers.
Keywords dermatitis allergic contact otitis externa hypersensitivity
Chronic otitis externa is characterized by an erythematous,
scaling, pruritic dermatitis of the auricle or external auditory
canal. It is a common problem affecting 310% of the patient
population,
1
which can be difcult to treat satisfactorily and
often requires multiple consultations by the otolaryngologist
for aural toilet, topical treatment and dressings. Several other
conditions should be considered amongst the differential
diagnosis of chronic otitis externa (Table 1), especially in
those patients who do not improve with intensive treatment.
It is important therefore for the otolaryngologist to consider an
allergic aetiology in all cases of chronic otitis externa. Such an
allergic reaction may take two basic forms: a contact derma-
titis or a dermatophytid reaction.
Allergic contact otitis
Allergic contact dermatitis is a type IV hypersensitivity
reaction that is also known as a delayed-type hypersensitivity
reaction.
2
It is characterized by severe pruritis leading to
scratching by the patient causing prolongation of the inam-
mation. The condition may be primary or secondary.
pri mary contact oti ti s
This occurs in an ear that was not previously inamed. It is an
allergic reaction of the external ear to antigens such as metals
(chrome, nickel, metal, silver, gold), chemicals (cosmetics,
nail polish, soaps, detergents, shampoo, hairspray, dyes, plas-
tics), rubber, leather or drugs.
3
The diagnosis may be evident
from the history when the patient recognizes the role of the
contact allergen in triggering his/her symptoms. It is important
for the otolaryngologist to enquire about specic primary
contact triggers.
Incidence and aetiology
Contact sensitivity can occur to earrings, especially those
containing nickel and chrome materials. Nickel is the com-
monest contact allergen. There is inammation of the skin
around the site of ear piercing (usually the lobule or around the
helix), which spreads to the antihelix. Scratching of the area
by the patient may cause further inammation and possible
superadded infections. Dermatitis may also be seen on the
Clin. Otolaryngol. 2002, 27, 233236
# 2002 Blackwell Science Ltd 233
Correspondence: Mr David Strachan, Consultant ENT Surgeon,
ENT Department, Bradford Royal Infirmary, Duckworth Lane,
Bradford BD9 6RJ, UK (e-mail: drstrachan@aol.com).
neck area where the earring touches. Patients with contact
sensitivity to nickel can usually easily be distinguished clini-
cally from those with chronic otitis externa. Nickel sensitivity
is common and affects around 10% of women.
4,5
In one
study,
6
nickel allergy was demonstrated in a group of 960
schoolgirls with a higher percentage (13% versus 1%) of
contact allergy demonstrated in those with pierced ears, thus
demonstrating a relationship between ear piercing and induc-
tion of nickel allergy. These patients should be advised to use
earring posts made of surgical stainless steel, gold or tita-
nium.
2
However, nine-carat gold contains a signicant amount
of nickel and sensitivity to gold earrings has also been
reported.
7
Some patients using hearing aids may develop a contact
allergy to components of and chemicals used in the manu-
facture of hearing aid moulds. Chronic otitis externa develops
in the area of skin that is in contact with the mould and can
lead to a reduction in the amplication of sound by the aid.
2
There are reports of contact allergy to substances including
cellular ester plastics, vinyl plastics, methyl-methacrylate,
polyvinyl chloride, vulcanized rubber or silicone, benzylper-
oxide, hydroquinone and aromatic amines.
8,9
Methyl metha-
crylate is the most common sensitizer. In a study of 25 hearing
aid users who had persistent irritation wearing their aid, 56%
were found to have a positive patch test to methyl-methacry-
late.
9
In a study of allergic contact dermatitis in 64 patients
with otitis externa, Pigatto et al.
10
found two patients to be
allergic to methyl methacrylate. Meding and Ringdahl
reported a study of 22 hearing aid users with chronic derma-
titis of the ear canal in which 27% patients had demonstrable
contact allergy to the ear mould on patch testing (to methyl
methacrylate and ethylene glycol methacrylate).
8
Of interest
in the same study was the fact that positive test reactions were
also noted to substances used in topical therapy, including
neomycin, quinolone, fragrance mix and Caine mix.
s e condary contact oti ti s (s e ns i ti zati on to
topi cal t re atme nt)
Prolonged use of topical preparations (prescribed or bought
over the counter) in the treatment of otitis externa can result in
sensitization of the auricle or external auditory canal leading
to an allergic reaction. If not recognized, this will confuse the
clinical picture and prolong treatment considerably.
Incidence
Contact sensitivity is common. In a series of 562 children
patch-tested, 13% had positive reactions, the most common
one being to neomycin.
11
Various studies have shown positive
allergic dermatitis and identied an allergen in 2359% of
patients with otitis externa.
10,12,13
In a study of 37 patients
12
with chronic otitis externa of at least 3 months duration, 59%
patients were shown to have positive skin patch testing to
substances used in the topical treatment of otitis externa. Of
these patients with a demonstrable hypersensitivity, 63%
showed a positive response to two or more substances. A
study of 142 patients with chronic otitis externa
13
revealed a
positive allergy to one or more compounds in topical pre-
parations in 40% of cases. Again, multiple positive reactions
on patch testing occurred frequently. Rasmussen reported a
positive patch test in 34 out of 98 patients with otitis externa,
mostly to drugs used topically in the ear canal.
14
Aetiology
Many otic preparations have been reported to cause sensitiza-
tion, including vehicle substances, and these are listed in
Table 2. Neomycin is the most common substance to produce
hypersensitivity in patients undergoing treatment for otitis
externa and, for this reason, many authors recommend avoid-
ing its use in treating otitis externa.
12
There is a signicant
crossover with framycetin and gentamicin in these
patients.
12,13,15,16
These three antibiotics are commonly used
as topical agents for the treatment of otitis externa in the UK.
In addition, patients with a contact allergy to neomycin may
react to systemic aminoglycosides that are closely related
chemically.
17
Benzalkonium chloride is a common preservative used in
topical preparations (e.g. Gentisone HC drops, Betnesol
drops, Predsol-N drops) for the treatment of otitis externa
and can also be responsible for producing an allergic reaction
Table 1. Possible diagnosis to be considered in chronic otitis
externa refractory to intensive treatment
Seborrhoeic dermatitis
Contact dermatitis/otitis
Psoriasis
Dermatomycosis
Malignant otitis externa
Carcinoma of the external auditory canal
Dermatophytid reaction
Table 2. Reported agents associated with allergic otitis exter-
na
3,10,12,13,19,25,26
Neomycin
Nickel sulphate 5%
Gentamicin sulphate 1%
Framycetin
Chloramphenicol
Quinolone mix 6%
Caine mix
Methyl-methacrylate
Bacitracin
Benzalkinium chloride 0.1% (preservative)
Methylrosaniline (Gentian violet)
Polymyxin B sulphate
Topical hydrocortisone
Methyl-p-oxybenzoate (preservative)
Propylene glycol (preservative)
Benzethonium chloride (preservative)
Thimerosal (merthiolate) (preservative)
234 S. Sood et al.
# 2002 Blackwell Science Ltd, Clinical Otolaryngology, 27, 233236
in some patients.
12
Other common preservatives that can
cause allergic reactions include thiomersal (used in Vista-
Methasone N drops), propylene glycol and sorbitol (used in
tri-adcortyl cream).
Topical steroids have also been reported to cause contact
sensitivity and it has been suggested that screening for steroid
allergy should be performed as part of the standard patch
testing in cases of suspected contact dermatitis.
18,19
Bismuth iodine parafn paste (BIPP) dressings are com-
monly used after otological procedures in the UK, and allergic
reactions to the iodine are not uncommon.
Diagnosis of contact otitis
A well taken history from a clinician aware of the possible
causes of allergic otitis may make a clear diagnosis of contact
otitis. However, in many cases, particularly in secondary
cases, the diagnosis may be difcult. In such cases, allergen
tests are indicated.
alle rge n t e s ts
Patch skin testing is the gold standard to identify an agent
causing allergic contact dermatitis.
20,21
Although the repro-
ducibility of patch testing is high, in a small number of cases
discordant tests have been reported.
22
Other skin tests and in
vitro allergen testing are less useful for evaluating allergic
contact dermatitis.
In patients suspected of allergic otitis externa, patch testing
using compounds that are in the topical preparations used by
the patient should be carried out. Any persistent/chronic cases
of otitis externa or cases in which there is a sudden are up
should undergo patch testing.
The patches are applied to the back of the patient for 48
72 h. Aluminium discs or patches are used to encourage
penetration of the allergen. After 4 days, the site is inspected
and the reaction graded. A positive test must be taken in
conjunction with the history and clinical ndings before a
specic diagnosis is made. As application and interpretation
of patch tests requires experience, it is important for the
otolaryngologist to involve the local dermatology department
in patch testing.
t re atme nt
The most important aspect of treatment is to identify the
antigen and avoid further contact. Treatment of allergic otitis
externa due to sensitization of topical preparations is by
stopping use of the otic drops and possible use of topical
steroids for a short period.
2,3
Once allergic otitis externa is
considered, patch testing is required. While waiting for patch
testing, patients should be given simple preparations avoiding
common sensitizers such as neomycin/gentamicin, topical
anaesthetics and preservatives. Ointment preparations gener-
ally have less preservatives than creams and otic drops.
Preparations containing multiple active ingredients, e.g. triad-
cortyl, should be avoided. Simpler preparations include 1%
hydrocortisone ointment, Fucidin H ointment, terracortil oint-
ment, Nystaform HC ointment and Daktacort ointment. More
potent steroid ointment preparations are also available. The
British National Formulary is good at listing excipients.
Repeated aural toilet may also be required.
Treatment for patients with a hearing aid mould allergy is to
use heat-cured moulds. This may be achieved by boiling the
mould, e.g. placing an acrylic mould in a pressure cooker for
approximately 45 min or by applying heat using a microwave.
Ultraviolet treatment of acrylic moulds may also reduce
antigenicity. In severe cases, the mould can be coated with
a thin layer of gold.
2
In cases of methyl-methacrylate allergy, a
mould containing less monomer or one made of silicone may
help.
Dermatophytid reaction
A dermatophytid reaction is a secondary allergic skin reaction
that occurs in specically sensitized individuals as a result of
haematogenous spread of fungi or their allergenic products
from a primary focus of fungal infection. The site of the
reaction may be the auricle or external auditory canal.
2,23
There are reports of patients with a dermatophytid reaction
presenting with a clinical picture of chronic otitis externa.
24
As this is an uncommon condition, patients often undergo
local topical treatment for chronic otitis externa before a
correct diagnosis is made.
24
The conditions required for a dermatophytid reaction
include:
1. A demonstrable primary focus containing the pathogenic
fungi, remote from the reaction.
2. Absence of fungi in the skin lesion at the reaction site.
3. Spontaneous resolution of the skin lesion with eradication
of the primary fungal infection.
4. Positive immediate skin test response demonstrating type 1
IgE-mediated reaction to intradermal test injection of
fungal antigen.
There is an absence of fungi in the skin lesion at the
dermatophytid reaction as the primary fungal focus is at a
site remote from the reaction, which is commonly the nails,
skin and vagina.
2,24
Treatment is directed at the primary
fungal focus. Desensitization with allergenic extract of the
infecting fungus has also been reported to give reasonably
satisfactory results.
2,24
Conclusion
Allergic otitis externa is common and may be primary or
secondary.
# 2002 Blackwell Science Ltd, Clinical Otolaryngology, 27, 233236
Allergic otitis externa 235
Primary allergic otitis occurs due to contact with antigens
such as metals (most commonly nickel), chemicals used in
cosmetics, nail polish, soaps, detergents, shampoo, hairspray,
dyes and plastics, rubber, leather or drugs. Of particular
interest to otolaryngologists is a reaction to hearing aid
moulds with methyl-methacrylate being the most common
sensitizer.
Allergic reactions to components of topical otic prepara-
tions (causing a secondary contact otitis) are common
amongst patients with prolonged otitis externa. Therefore,
in patients with a clinical picture of chronic otitis externa
resistant to therapy, or with pruritis as a predominant symp-
tom, allergy to topical medications must be considered.
Patients with possible allergic otitis externa (both primary
and secondary) should be patch-tested for contact allergy. This
should be in conjunction with the dermatology department
using products that the patient comes in to contact with or, in
possible secondary cases, those products contained in topical
preparations used by the patient. The most common antibiotic
treatment to be associated with development of an allergic
otitis externa is neomycin and its prolonged use in refractory
cases should be avoided. If the patch test is positive then the
treatment should be stopped and further treatment with topical
steroids considered.
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