Cassaday, Kacie DO; Vazquez, Gerardo MD; Wright, Justin M. MD
Although not thought to be a major cause of ailments in athletes, ear problems are encountered in specific populations, most commonly in aquatic athletes. Due to its importance for hearing and balance, ailments affecting the ear may lead to significant morbidity. Many of the common conditions of the ear in the athlete are preventable through patient education and use of protective equipment. This review will focus on the diagnosis, management, and prevention of the most common ear problems affecting athletes.
The ear is divided into three main compartments: the external ear, the middle ear, and the inner ear. The external ear collects sound and is composed of the pinna and external auditory canal. It acts as a conduit for sound to the tympanic membrane, which forms the border between the external and middle ear. The middle ear is located within the petrous portion of the temporal bone and contains the auditory ossicles: the malleus, incus, and stapes. The ossicles help to transmit sound waves to the inner ear via the oval window. The middle ear is connected to the nasopharynx via the auditory (or Eustachian) tube, which allows for pressure equalization between the middle ear and the external environment. The inner ear is separated from the middle ear by the oval window and is responsible for hearing, via the cochlea, and balance, via the vestibule, utricle, saccule, and semicircular canals (5).
Otitis externa, or inflammation and infection of the external auditory canal, is a common disorder of aquatic athletes. There are a number of risk factors for otitis externa, but typically, the process leading to infection begins with a disruption of the cerumen in the external auditory canal. Cerumen, or earwax, coats and protects the external auditory canal from bacteria and is the first line of defense against infection for the external ear. When water enters the external auditory canal and is not cleared from the canal in a timely manner, the water will wash away the cerumen, altering the normal acidic pH of the external auditory canal. This produces favorable conditions in the external auditory canal for infection (21). Other risk factors for the development of otitis externa include moisture, high environmental temperatures, insertion of foreign objects such as earplugs or cotton tip applicators, and chronic dermatologic diseases such as eczema or seborrheic dermatitis (10).
Classically the patient with otitis externa will present with ear pain (otalgia) and drainage (otorrhea) (21). On physical examination, the auditory canal may be edematous, erythematous, and with discharge. The patient also may complain of pain with manipulation of the tragus or with insertion of the otoscope. Once visualized, otorrhea may be variable in color from white to gray or green and potentially malodorous (21). Visualization of the tympanic membrane on examination is of utmost importance. Without visualization, an acute otitis media with rupture of the tympanic membrane cannot be excluded. As the treatment of otitis externa and otitis media differ, it is important to make the correct diagnosis. Furthermore it is necessary to ensure the tympanic membrane is intact before procedures such as ear lavage is performed to avoid damaging the ossicles of the inner ear, which can lead to hearing loss (21).
The mainstay for treatment of acute otitis externa is external auditory canal hygiene, elimination of the bacterial infection, and pain control (21). External auditory canal hygiene is crucial because without removal of the discharge, the infection will persist. The moist discharge provides an optimal environment for continued infection and prevents the topical medications from penetrating and reaching the surface of the external auditory canal (21). Cleansing can be achieved through a variety of methods, although gentle suction under direct visualization of the tympanic membrane or sweeping of secretions with a cotton swab is the most common (21). In the setting of extreme swelling of the external auditory canal, a medication soaked wick may be inserted into the external auditory canal (21). The wick will help pull moisture from the canal while delivering medication to the affected area. While the wick is in place, the patient will need regular follow-up every 1 to 2 d to monitor the degree of swelling and for improvement of symptoms (21). Once the swelling of the external auditory canal has decreased, the wick will fall out on its own and topical eardrops can be applied directly to the canal for the remainder of the course of treatment.
After the external auditory canal has been cleansed, topical medication can be applied. Treatment involves acidification of the canal, restoring its natural defense against bacteria. Typically this is achieved with otic suspensions, which also contain antibiotics, as patients treated with 2% acetic acid solution alone have longer duration of symptoms and lower cure rate (21). Most commonly, combinations of topical fluoroquinolones and steroids, covering the most common pathogens of Pseudomonas and Streptococcus species, have been the mainstay of treatment. Although costly, the otic fluoroquinolones are preferred because they require less frequent application, increasing patient compliance. Also, with the fluoroquinolone/topical steroid combination, there is no risk of ototoxicity if a ruptured tympanic membrane has been missed and the medication was to make it into the inner ear (21). In any case of suspected otitis externa that is not improving with standard treatment regimens, or if the patient has an immunodeficiency or diabetes mellitus, frequent reevaluation is crucial as a more serious infection, which will require systemic antibiotics, should be suspected (21).
Pain control is an essential component in the treatment of otitis externa. In most cases, pain control can be achieved with oral NSAIDs. If the patient complains of pain out of proportion to physical examination findings or has continued pain after treatment, additional evaluation may be required to assess for other more ominous conditions such as malignant otitis externa, in which the infection has spread to the adjacent temporal bones and potentially erode into the brain (21). These patients require urgent evaluation for treatment including antibiotics and debridement by ENT.
Treatment duration is variable but is usually 5 to 7 d total, continuing 2 to 3 d after symptom resolution (10). There is little consensus for the recommendations regarding returning to water sports after treatment of otitis externa. According to the treatment recommendations, most athletes would return to the water after approximately 1 wk. Other studies have suggested an athlete can return to the water after 2 to 3 d of treatment if there is full resolution of the pain, and yet, others would suggest the athlete can return to swimming while undergoing treatment with the use of tight fitting earplugs (6,15). There are no established National Collegiate Athletic Association return-to-play guidelines.
Prevention of otitis externa centers around maintenance of an acidic environment within the external auditory canal and prevention of trauma (21). While keeping the external auditory canal dry is a priority, the use of cotton swabs is cautioned. The cotton swabs can strip the external auditory canal of the protective cerumen, cause trauma, or lead to cerumen impaction. There is also little evidence to support the beneficial effect of earplugs; however, much like with the use of cotton swabs, the complications of local trauma, infection, and cerumen impaction have been cited as adverse events (21). Generally the athlete should try to remove water from the external auditory canal via shaking the head or through use of a hair dryer on the lowest heat setting to dry the canal (21). Some studies also advocate for use of acetic acid ear drops to restore the canal’s natural pH after swimming, but most physicians feel this is too stringent (21). For swimmers, the most beneficial barrier protection is a properly and tightly fitting swim cap (6,15).
External Auditory Canal Exostoses (Surfer’s Ear)
External auditory canal exostoses, or Surfer’s ear, are bony growths in the external auditory canal that develop as a result of exposure to cold water (17). The critical temperature for the development of external auditory exostoses has not been established (4). The proposed mechanism for development of the exostoses involves reactive hyperemia within the external auditory canal as a result of exposure to cold water and which stimulates the osteoclasts of the periosteum leading to bone formation within the external auditory canal (4).
This excess bone formation is problematic for several reasons. The exostoses can impede normal drainage of the external auditory canal. As a result, cerumen, debris (such as sloughed skin cells), and water can accumulate behind the exostoses with no means for draining. This predisposes the patient to infection. Treatment of infection behind the exostoses can be difficult to achieve due to limited accessibility of the area and the inability of the area to drain adequately.
The patient typically will present complaining of otalgia, hearing loss, or otorrhea or present with signs of infection, although in some patients, the exostoses may be an asymptomatic incidental finding. Examination with an otoscope will reveal either partial or complete obstruction of the external auditory canal that is not caused by a foreign body.
Treatment of external auditory exostoses depends on the symptoms and disability of the patient. Small exostoses that do not occlude the external auditory canal often do not require intervention, only monitoring for symptoms and growth over time. Surgical excision is indicated for exostoses that are large, partially or fully obstructive, or are causing the patient significant discomfort, hearing loss, or recurrent ear infections.
External auditory exostoses are preventable with use of earplugs or tight fitting body suits with head protection (17). These barriers prevent the cold water from entering the external auditory canal thus preventing the chain of events that leads to the formation of the exostoses.
Otitis media is an infection of the middle ear. Typically this infection affects children, but it also can be seen in adults. Commonly otitis media occurs in the setting of Eustachian tube dysfunction, leading to a negative pressure in the inner ear with associated fluid development and infection. The infection can be caused by viruses or bacteria, with Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis being the most common bacterial pathogens.
Patients with acute otitis media typically will present with upper respiratory tract infection symptoms along with ear pain or fullness. Fever may be present. Examination with an otoscope often will show a dull, erythematous tympanic membrane that is nonmobile with pneumatic otoscopy (10). Alternatively the tympanic membrane also can appear to be bulging with visualization of purulent fluid in the inner ear (10).
The treatment for acute otitis media in athletes typically involves oral antibiotics, such as penicillins (10). The decision not to treat with antibiotics also can be an acceptable approach if the physician believes the infection is viral in origin. In either scenario, analgesics are useful for symptomatic treatment and patient comfort (10). Athletes with acute otitis media should not return to swimming, diving, or travel via airplane until tympanic membrane mobility, as demonstrated with the pneumatic otoscope, has returned to normal (15). Fluctuations in pressure substantial enough to rupture the tympanic membrane can occur in water as shallow as 4 ft (10). Once tympanic membrane mobility has normalized, the patient can return to sport without restrictions even if this occurs prior to the completion of the antibiotic course. If the athlete has ruptured the tympanic membrane, the tympanic membrane should be healed prior to returning to water sports.
Special Precautions for Children with Tympanostomy Tubes
Tympanostomy tubes, also known as ventilation tubes or grommets, typically are placed in younger patients because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy (18). For many years, there has been controversy among otolaryngologists about the water restrictions and the use of protective equipment for children status after ventilation tube placement (3). However recently published guidelines recommend that clinicians should not encourage routine water precautions, prophylactic water precautions with the use of earplugs or headbands, or the avoidance of swimming or water sports in patients with tympanostomy tubes (18). Normal surface swimming is safe and does not cause water to enter the middle ear or increase the risk of middle ear infection. When the athlete swims underwater, water potentially could enter the middle ear, but if the exposure is not prolonged, this does not increase the risk for acute otitis media (13). Special instances in which children with tympanostomy tubes may consider the use of earplugs are when swimming at a depth greater than 6 ft of water, when swimming in lakes or nonchlorinated pools, when there is pain or discomfort when water enters the ear canal, or when the patients have frequent or prolonged episodes of ear discharge (18). Generally diving is not recommended for children with tympanostomy tubes due to the increased risk of water entering the middle ear, leading to increased risk of infection (18).
Cerumen impaction also can prove to be problematic in athletes. Cerumen, or ear wax, is a mixture of secretions, sloughed skin cells, and hair that coats and protects the external auditory canal (14). The mechanism for cerumen impaction varies. Some patients are cerumen overproducers and, due to the sheer volume of cerumen produced, are predisposed to frequent impactions. Other patients insert objects into their ears, such as earplugs, hearing aids, or cotton tip applicators, which push the cerumen further into the external auditory canal, creating an impaction (14). On presentation, the patient may complain of sensation of ear fullness, decreased hearing, tinnitus, vertigo, or ear discomfort or itching. Visualization with an otoscope will show cerumen in the external auditory canal with or without complete obstruction of the tympanic membrane based on severity. There are many treatment methods for cerumen impaction, including irrigation, ceruminolytic medications, or use of curette for manual removal (9,14). Patient counseling should be provided also with information on ear canal hygiene and avoidance of placing objects in the external auditory canal such as cotton tip applicators for prevention of future episodes.
Much like the general population, external auditory canal foreign bodies also are seen in athletes. The patient may complain of fullness, discomfort, or decreased hearing of the affected ear in the context of a possible history of insertion of an object into the ear. Earplugs are used commonly in athletes exposed to water or loud noises to protect the ear. Earplugs that are composed of silicone or wax tend to soften and firmly attach to the walls of the external auditory canal when the body temperature rises (22). After this softening and adhesion occurs, these earplugs are very difficult to remove for the athlete and the physician (22). On otoscopic examination, the object should be visualized. Depending on the size of the foreign object, patient discomfort, and availability of the proper equipment for visualization and removal, this procedure usually can be an in-office or emergency room procedure. However if the object is not well visualized or if there is difficulty in retrieval, the patient should be referred to an otolaryngologist for definitive care.
Auricular Hematoma and Cauliflower Ear
Auricular hematoma is an accumulation of blood in the subperichondrial space. It is seen often as a result of blunt trauma secondary to sports injuries, most commonly in boxing, wrestling, and martial arts (8). The perichondrium of the ear, which is a dense, irregular connective tissue membrane around the cartilage of the ear, supplies nutrients to the auricular cartilage. It is thought that when there is trauma to the ear, blood or serum forms a layer between the perichondrium and the cartilage. If left untreated, the separation of the perichondrium from the cartilage leads to cartilage infection and death. New cartilage and fibrous tissue are formed following the cartilage loss and necrosis. This fibroneocartilage production causes a cosmetic deformity known as cauliflower ear (8).
Evaluation of the athlete who has experienced auricular trauma should involve a complete examination to rule out any life threatening injuries, such as skull fracture. Patients also must undergo otoscopic examination for evaluation of tympanic membrane rupture and should have his or her hearing evaluated (5,8). An athlete with an auricular hematoma will complain of pain and pressure in the outer ear. Physical examination reveals a swelling or fluctuant area in the cartilaginous area of the outer ear (5,7).
Successful auricular hematoma treatment involves early recognition, early drainage, and prevention of reaccumulation. Drainage is achieved by either needle aspiration or incision and drainage. Needle aspiration involves the application of local anesthetic to the ear, drainage with a large bore needle, and placement of a thermoplastic splint bolster for 3 to 7 d (5,8). Another option is to perform an incision and drainage of the hematoma using a scalpel blade (5).
Prevention of the reaccumulation of fluid or blood may be achieved by the use of a compressive bolster or via a bolsterless approach. The most commonly used bolsters are the thermoplastic splint or a dental roll affixed to the pinna via sutures (5,7). Bolsterless techniques include using absorbable mattress sutures to close dead space following incision and drainage. This approach has the potential advantage of allowing immediate return to activity (11,19). Other approaches include using an angiocatheter left in place to allow for drainage and the use of magnets to prevent reaccumulation (2,16).
For athletes competing in high-risk sports, including boxing, wrestling, rugby, water polo, and martial arts, protection should be worn to cover the ear and prevent trauma that may lead to an auricular hematoma.
Cauliflower ear is a cosmetic deformity resulting from abnormal cartilage and fibrous tissue development following an untreated or inadequately treated auricular hematoma. Ideal treatment involves excising the abnormal cartilage and reconstructing the normal cartilage to recreate the ear’s natural contours (8).
Diving and Ear Barotrauma
The growing interest in the water sport diving has opened a door for physicians to become knowledgeable in “diving medicine.” This water sport and its environment are ruled by the changing ambient pressures, which must be compensated for successfully by the diver in order to avoid injury or death. As the diver maneuvers downward, he or she will be experiencing an increase in the sea’s ambient pressure at a rate of 1 atm (760 mm Hg) for every 10 m (33 ft) (12). This natural process will bring into play numerous pathophysiological changes in the ear if the diver is unable to adjust to the changing water pressure.
Barotrauma refers to the damage the ear experiences from its inability to equalize pressure. Boyle’s law states that the volume of gas is inversely proportional to its pressure (20). In other words, increasing pressure reduces the gas’s volume and vice versa. Both the middle ear and inner ear are susceptible to barotrauma. Middle ear barotrauma, or ear squeeze, occurs during descent when the diver fails to compensate for and equalize the water’s pressure in the middle ear. This will cause the diver to be afflicted with pain, vertigo, tinnitus, and conductive hearing loss (12,20). Otoscopic examination findings vary from tympanic membrane injection to hemotympanum to tympanic membrane rupture (5,12). Treatment involves a combination of decongestants and abstinence from the sport until fully recovered (20).
Although the Valsalva maneuver can help avoid barotraumas, forceful implementation of the Valsalva maneuver can lead to inner ear barotrauma. A pressure gradient between the middle and inner ear may form, leading to rupture of the oval or round windows, causing perilymph leakage (12,20). The physical impairment is similar to that of middle ear barotrauma with pain, vertigo, tinnitus, and, in this case, sensorineural hearing loss. The afflicted diver’s treatment will be bed rest, head elevation, avoidance of straining, and referral to an otolaryngologist (12,20).
The inner ear is also subject to decompression sickness (DCS), where gas bubble formation occurs in the inner ear during ascent from a deep-water dive. Symptoms of inner ear DCS include acute vertigo, nystagmus, tinnitus, and nausea with vomiting (5,12). The mainstay of treatment for inner ear DCS is hyperbaric oxygen therapy. However hyperbaric oxygen is contraindicated for inner ear barotrauma, so distinguishing between these two entities is of the utmost importance (1).
Prevention of middle and inner ear barotrauma can be achieved by equalizing pressure via the Valsalva maneuver throughout the descent. The diver should descend slowly so as not to induce large pressure changes. The use of nasal or systemic decongestants may help to allow for pressure equilibration in the ear (1,12). Limiting dive depths to less than 100 ft and practicing proper decompression techniques during ascent may prevent inner ear DCS (5).
The ear is a unique structure, given its role in hearing and balance. Problems affecting the ear can lead to significant morbidity. Prompt identification and treatment of infections and injuries are key to minimizing consequences. For those athletes involved in the high-risk sports mentioned previously, education about preventive measures and the use of protective equipment might mean the difference between a day of recreation and a life-changing event.
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