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193]

Original Article

Risk factors of acute otitis externa seen in

patients in a Nigerian tertiary institution
Mohammed Abdullahi, D. Aliyu
Department of Otorhinolaryngology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

A B S T R A C T
Background: Acute otitis externa is a common clinical problem which is associated with preventable risk factors. Objective: The
aim of this study is to determine the practices that are risk factors in patients with acute otitis externa in a Nigerian tertiary institution.
Patients and Methods: This was a 6‑month cross‑sectional study of patients with acute otitis externa carried out between April
and September 2013 at the Ear, Nose, and Throat Clinic of the Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria.
Results: A total of 2350 patients were seen during the study period, of which 88 (3.7%) were diagnosed with acute otitis externa. The
males and females were 32 (36.4%) and 56 (63.6%), respectively, with a ratio of 1:1.8 The age range was 3 months to 70 years, with the
mean age of 18.9 years. Self‑ear cleaning with cotton bud 65 (73.9%) constituted the majority of object introduced into the ear canal(s)
and the reasons for self‑ear cleaning were because of itching of the ear(s) in 47 (53.4%), habitual 9 (10.2%), and perceiving that the
ears were dirty 32 (36.4%). The introduction of extraneous moisture into the ears was seen in 46 (52.3%) including self‑medication
with topical antibiotic, instilling plain and soapy water in the ear canal(s), and swimming. The comorbid conditions which are known
risk factors for otitis externa were seen in 35 (39.8%) patients, of which allergy was the most frequent with 22 (25%), followed by
diabetic mellitus 7 (8%) and AIDS 6 (6.8%). Only 14 (16%) of these patients had their comorbid conditions diagnosed at their first
presentation. Conclusion: Self‑ear cleaning with cotton bud was the major risk factor seen in our patients with otitis externa, followed
by the introduction of extraneous moisture into the ear canals and untreated comorbid risk factors for acute otitis externa. These risk
factors are preventable through creation of awareness and prompt treatment of other associated disease conditions.

Keywords: Acute otitis externa, prevention, risk factors

INTRODUCTION Otitis externa usually represents an acute bacterial

Otitis externa is an inflammation or infection of the
external auditory canal.[1] This condition can be acute
or chronic, with the acute form affecting 4 in 1000
persons annually.[2] Acute otitis externa is unilateral in
90% of patients, and it is uncommon below the age of
2 years. The peak age incidence is from 7 to 12 years
and declines after 50 years of age.[3,4]
Corresponding Author: Dr. Mohammed Abdullahi,
Department of Otorhinolaryngology, Usmanu Danfodiyo
University Teaching Hospital, Sokoto, Nigeria.
E‑mail: mabdullahi7174@gmail.com
infection of the skin of the ear canal which is
commonly attributable to Pseudomonas aeruginosa or
Staphylococcus aureus.[5] The infections can also be due
to other bacteria, viruses, or fungal agents.
Several factors can contribute to external auditory
canal infection and the development of otitis externa:
Absence of cerumen, high humidity, retained water
in the ear canal, increased temperature, local
trauma (e.g., use of cotton swabs), anatomical
anomaly of the external auditory canal, dermatological
conditions, etc.[6,7]

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DOI:
10.4103/1118-8561.192395 Cite this article as: Abdullahi M, Aliyu D. Risk factors of acute otitis externa
seen in patients in a Nigerian tertiary institution. Sahel Med J 2016;19:146-9.

146 © 2016 Sahel Medical Journal | Published by Wolters Kluwer - Medknow

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Abdullahi and Aliyu: Risk factors of acute otitis externa

Otitis externa is a clinical diagnosis based on the
symptoms and signs such as pain, itching, edema, and
erythema of the external auditory canal with purulent
otorrhea and debris in the meatus.[7]
Risk factors for otitis externa are well documented in the
literature;[6‑8] there is dearth of information on the risk
factors practiced by patients with acute otitis externa
in our environment.
The aim of this study is to determine the practices that
are risk factors for acute otitis externa and the influence
of the known comorbid conditions usually associated
with it in patients seen in the Ear, Nose, and Throat (ENT)
Clinic, of the Usmanu Danfodiyo University Teaching
Hospital (UDUTH), Sokoto, and to create awareness on
prevention of the disease in our environment.
PATIENTS AND METHODS
This was a 6‑month cross‑sectional study using self‑ and
interviewer‑administered questionnaires (for patients
with no educational background). The study population
was all consecutive patients who presented for treatment
at the ENT Clinic of the UDUTH, Sokoto, Nigeria (a
tertiary institution with a referral from other centers
in the neighboring states of Northern Nigeria: Kebbi,
Niger, and Zamfara), from August 2013 to January 2014.
This study was carried out after the approval from the
Ethical Committee of the reference institution.
Data were analyzed using Statistic Package for Social
Science (SPSS) Version 18 (Chicago: SPSS Inc.) for
mean, standard deviation, and frequency distributions.
RESULTS
A total of 2350 outpatients were seen during the study
period, of which 88 (3.7%) were diagnosed with acute
otitis externa. The males and females were 32 (36.4%) and
56 (63.6%), respectively, with male to female ratio of 1:1.8.
The age range was 3 months to 70 years, with the mean
age of 18.9 years. Majority of these patients were below
the age of 10 years, with 30 (34.1%) patients [Figure 1].
Self‑ear cleaning with the use of various objects were seen
in all patients with acute otitis externa for which the use
of cotton bud 65 (73.9%) constituted the majority of object
introduced into the ear canals, and the other objects used
for self‑ear cleaning include use of both fingertip and cotton
bud 8 (9.1%), broomstick 6 (6.8%), fingertips 4 (4.5%), pen
covers 4 (4.5%), and matchstick 1 (1.1%) [Table 1]. The
reasons for self‑ear cleaning were because of itching of the
ear canals 47 (53.4%), habitual 9 (10.2%), and perceiving

The clinical diagnosis of acute otitis externa was based

on the major presentations such as rapid onset (usually
within 48 h) in the past 3 weeks of otalgia, itching of the
ear canal or fullness in the ear canal, and the signs of ear
Figure 1: Age distribution in percentages
canal inflammation: Tenderness of the tragus/pinna or
both with or without otorrhea, regional lymphadenitis.[9]
Table 1: Risk factors for acute otitis externa and the
associated comorbid conditions
The questionnaires completed consist of biodata and
Practiced risk factors ad comorbid conditions Numbers (%)
risk factors for otitis externa which includes use of
Objects introduced into ear canal(s)
cotton bud and other objects for self‑ear cleaning, Cotton bud 65 (73.9)
introduction of extraneous moisture into the ear canals: Fingertip and cotton bud 8 (9.1)
Broomstick 6 (6.8)
Use of topical ear drops, swimming, instilling of plain
Fingertip 4 (4.5)
and soapy water, and the reasons for that history of Pen covers 4 (4.5)
comorbid conditions associated with acute otitis externa Matchstick 1 (1.1)
Extraneous moisture
such as allergy, diabetic, AIDS, and others.
Prolonged use of topical ear drops 21 (23.9)
Instilling water into the ear canal(s) 15 (17)
Inclusion criteria were patients with acute otitis externa Instilling soapy water in the ear canal(s) 6 (6.8)
who were first seen at the ENT Clinic and the exclusion Swimming 4 (4.5)
Comorbid conditions
criteria were patients with discharging ears from otitis Allergy 22 (25)
media, chronic otitis externa, and referred otalgia from Diabetic mellitus 7 (8)
other causes. AIDS 6 (6.8)

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Abdullahi and Aliyu: Risk factors of acute otitis externa
that the ears were dirty 32 (36.4%) [Figure 2]. Other risk
factors practiced by the patients with acute otitis externa
include deliberate introduction of extraneous moisture
into the ear canals such as self‑medication with topical
antibiotic ear drops 21 (23.9%), instilling plain water into
the ear canal(s) 15 (17%), instilling soapy water into the
ear canal(s) 6 (6.8%), and swimming 4 (4.5%) [Table 1].
The comorbid conditions which are risk factors for acute
otitis externa are allergy 22 (25%), diabetic mellitus 7 (8%),
and AIDS 6 (6.8%). Out of these 35 (39.8%) patients with
comorbid conditions, 14 (40%) patients were not aware
of their comorbid conditions. Forty (45.5%), 38 (43.2%),
and 10 (11.4%) had right, left, and bilateral acute otitis
externa, respectively.
DISCUSSION
Acute otitis externa is a common clinical condition.[10]
This study showed that this condition is more common
in females, which agrees with the studies by Amutta
et  al. and Rowlands et  al.[10,11] Probably, the female
preponderance may be explained by the early
presentation and frequent habits of engaging in self‑ear
cleaning that predisposes to acute otitis externa.
The accessible location of the external ear will explain
its susceptibility to various risk factors. These various
risk factors are well enumerated in the previous studies
on otitis externa.[1,6‑8,12] This study showed that all
patients with acute otitis externa practiced self‑ear
cleaning with cotton‑tip application as the leading
object introduced into the ear canal(s), which agrees
with other previous studies.[1,11]
Apart from the use of cotton‑tip applicator and other
objects for self‑ear cleaning, 52.3% of the respondents
Figure 2: Reasons for self-ear cleaning in percentages
148 Sahel Medical Journal / July-September 2016 / Vol 19 | Issue 3
introduced extraneous moisture into the ear canal(s);
this can cause maceration of the canal skin and
encourages destruction of the protective barrier and
hence a favorable condition for bacterial growth
and forming good environment for otomycosis.[12‑14]
Cerumen plays an important role in the protection of
the external auditory canal by creating an acidic pH
which is hostile to infection;[3,15] this can be altered
by extraneous moisture exposure, soapy deposit, and
aggressive cleaning,[3] especially in the form of self‑ear
cleaning.
Although the study showed respondent practices that
predispose them to acute otitis externa, prospective
studies are needed to determine if these practiced
risk factors are actually responsible for this disease
condition.
Acute otitis externa can progress to a chronic form either
when the risk factors persist or when it is inadequately
treated, especially the risk can be very significant
when malignant otitis externa develops in patients
with immunosuppressive conditions such as HIV and
diabetes mellitus.[16] Therefore, we recommend public
enlightenment programs, especially for mothers who
frequently engaged in self‑ear cleaning and introduction
of extraneous moisture into the external auditory canal
for the purpose of removing wax and early diagnosis and
prompt treatment of patients with immunosuppression.
CONCLUSION
Self‑ear cleaning with various objects, especially with
cotton bud, introduction of extraneous moisture into
the ear canal(s), and untreated comorbid conditions
are the risk factors practiced by our patients with acute
otitis externa; they are preventable through creation of
awareness, especially to mothers who frequently engage
in self‑ear cleaning for their children, and to promote
routine medical checkup for early diagnosis and prompt
treatment of associated comorbid condition(s).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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